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PLATE   I 


Mottled  eruption 
from  the  arm  of 
same  case. 


Severe  Case  of  Scarlet  Fever,  showing  eruption  at  its  height.  For 
strawberry  tongue  of  same  case,  see  Plate  XVII.  (Original.)  (Painted 
from  a  case  in  the  Riverside  Hospital. ) 


DISEASES 


OF 


INFANCY  AND  CHILDHOOD 

THEIR 

Dietetic,  Hygienic,  and  Medical  Treatment 


A  TEXT-BOOK  DESIGNED  FOR  PRACTITIONERS 
AND  STUDENTS   IN  MEDICINE. 


BY 

LOUIS  FISCHER.  M.D. 

ATTENDING    PHYSICIAN    TO    THE    WILLARD    PARKER    AND    RIVERSIDE    HOSPITALS  OF    NEW  YORK    CITY 

ATTENDING    PEDIATRIST   TO   THE  SYDENHAM   HOSPITAL;     FORMER    IXSTRUCIOR   IN    DISEASES 

OF  CHILDREN  AT  THE  NEW  YOEK  POST-GRADUATE  MEDICAL  SCHOOL  AND  HOSPITAL, 

ETC.,   ETC.  ;    FELLOW  OF  THE  NEW  YORK  ACADEMY  OP  MEDICINE. 


THIRD      EDITION 


WITH  THREE  HUNDRED  AND  THREE  ILLUSTRATIONS,  SEVERAL 

IN    COLORS,    AND    TWENTY-NINE    FULL-PAGE 

HALF-TONE  AND  COLOR  PLATES. 


ivl.ff«iitt^-aai«rffi.T 


PniLADELPIIIA 

F.  A.  DAVIS   COMPANY,    Publishers 
1910 


IVo 


COPYRIGHT,  1907 
COPYRIGHT,  1908 
COPYRIGHT,  1910 

BY 
F.   A.   DAVIS  COMPANY 

[Registered   at  Stationers'  Hall,  London,  Eng.  I 


Philadelphia,  Pa..  U.  S.  A. 

Press  of  F.  A.  Davis  Company 

1914-16  Cherry  Street 


TO 


ADOLF  BAGINSKY,  M.D. 

PROFESSOR  OF  DISEASES    OF    CHILDREN   AT   THE   BERLIN    UNIVERSITY,  AND 

DIRECTOR    OF   THE  EMPEROR  AND  EMPRESS  FREDERICK 

CHILDREN'S   HOSPITAL,  BERLIN, 


AS  A  TOKEN  OF  GRATITUDE  FOR  HIS  MANIFOLD  COURTESIES 
THIS  WORK  IS  MOST 


AFFECTIONATELY  INSCRIBED. 


PREFACE   TO   THE   THIRD    EDITION. 


A  THOROUGH  revision  has  been  attempted.  tSeveral  new  chapters  have 
been  added  to  conform  with  scientific  progress.  For  example :  By  means 
of  research  work  the  method  of  diagnosis  and  more  specially  the  treatment 
of  cerebrospinal  meningitis  with  Flexncr  antimeningitis  serum,  has  been 
entirely  changed.  Intraspinal,  also  intraventricular,  methods  of  treatment 
are  illustrated  and  described. 

Infant-feeding  has  been  adapted  to  conform  with  common  sense 
methods.  I  have  been  guided  chiefly  by  bedside  observations  in  the  Ijabies' 
wards  of  my  hospital  service  for  the  changes  made  and  suggested.  The 
caloric  method  of  feeding  has  been  added.  A  new  method  for  the  preserva- 
tion of  human  milk  is  given.  An  important  observation  is  described  in  a 
new  article  on  Lordotic  Albuminuria. 

In  septic  diphtheria  the  intravenous  injection  of  antitoxin  has  been 
added.  The  h«mostatic  value  of  injections  of  horse  serum  in  cases  of 
ha?mopliilia,  and  its  value  in  post-operative  tonsillotomy,  is  described. 

Xew  articles  on  Scabies,  Indicanuria,  Pyuria,  Acetonuria,  and  Diabetes 
have  been  added.  To  make  room  for  the  above  some  lengthy  articles  Avere 
condensed. 

To  thoroughly  complete  this  revision  many  illustrations  have  been 
redrawn  and  new  ones  substituted.  Tw-o  new  plates  illustrating  the  Von 
Pirquet  reaction,  so  valuable  in  diagnosis  of  tuberculosis  and  scrofulosis, 
have  been  added.  A  new  plate  showing  the  method  of  intraventricular 
injection  of  meningitis  serum  is  shown,  and  in  the  same  chapter  the  proper 
method  of  performing  luml)ar  puncture  is  illustrated.  An  illustration  of 
facial  paralysis,  two  illustrations  of  encephalocele,  and  two  illustrations  of 
omphalocele,  likewise  a  microscopical  illustration  showing  the  threads  and 
spores  of  sprue  have  been  inserted. 

Many  points  will  be  found  incorporated  with  especial  value  to  teachers 
in  the  various  colleges  and  likewise  for  the  instruction  of  students,  and  such 
diagnostic  aids  will,  I  hope,  prove  valuable  to  the  busy  practitioner. 

For  manifold  expressions  of  approval  accorded  to  previous  editions,  T 
am  indebted  to  the  profession. 

Louis  Fischer. 

162  West  87th  Street. 


PREFACE. 

Eapid  strides  have  been  made  in  the  diagnosis  and  especially  in  the 
treatment  of  diseases  in  children.  The  twentieth  century  has  perfected 
many  dark  points  in  pediatrics.  Along  with  the  progress  in  diagnosis, 
therapeutics  has  been  entirely  remodeled. 

The  development  of  bacteriology  has  added  new  methods  of  diagnosis, 
aided  prognosis,  and  further  perfected  specific  treatment  for  various  infec- 
tious diseases.  A  comparison  of  the  treatment  of  diphtheria  in  vogue 
twenty  years  ago  with  that  of  the  antitoxin  treatment  of  to-day,  is  cited 
as  an  instance  of  progress.  The  operation  of  intubation  instead  of  trache- 
otomy for  acute  and  subacute  obstruction  to  the  upper  air  passages  is 
another  instance  of  progress  in  therapeutics. 

Our  advance  in  the  diagnosis  and  the  modem  treatment  of  tubercu- 
losis has  been  the  means  of  saving  many  lives. 

In  this  work,  infant-feeding  in  all  its  phases,  maternal  nursing,  Avet 
nursing,  and  hand  feeding  with  all  home  modifications  for  bottle  feeding, 
are  carefully  considered  and  given  special  attention.  The  disorders  arising 
from  improper  feeding  have  been  given  prominence  owing  to  the  impor* 
tance  of  the  subject. 

The  growing  child  is  very  susceptible  to  infectious  diseases,  hence 
this  important  part  has  received  my  most  earnest  attention.  The  diseases 
of  the  digestive  tract  and  diseases  of  the  respiratory  tract  have  in  their 
turn  been  considered. 

Clinical  observations  in  Europe,  as  well  as  while  oni  duty  as  an  attend- 
ing physician  to  the  largo  service  of  the  Eiverside  and  Willard  Parker  Hos- 
pitals, have  given  me  an  abundant  opportunity  for  comparing  various 
methods  of  treatment. 

This  book  has  been  divided  into  twelve  parts: — 
I.  The  New-born  Infant. 
II.  Abnormalities  and  Diseases  of  the  Newly-born. 

III.  Feeding  in  Health  and  Disease. 

IV.  Disorders  Associated  with  Improper  Nutrition,  and  Diseases  of  the 

Mouth,  (Esophagus,  Stomach,  Intestines,  and  Eectum. 
V.  Diseases  of  the  Heart,  Liver,   Spleen,  Pancreas,   Peritoneum,  and 
Genito-urinary  Tract. 

(v) 


yi  PREFACE. 

"\'L  Diseases  of  the  Eespiratory  System. 
\ll.  The  Infectious  Diseases. 
Vlll.  Diseases  of  the  Blood,    Lyiii2)h    Ghmds    or    Nodes,    and    Ductless 
Glands. 
IX.  Diseases  of  the  Nervous  System. 
X.  Diseases  of  the  Ear,  Eye,  Skin,,  and  Abnormal  Growths. 
XI.  Diseases  of  the  Spine  and  Joints. 
XII.  Miscellaneous. 

The  greatest  stress  has  been  laid  on  the  diagnosis,  symptoms,  and 
treatment  which  are  so  necessary  at  the  bedside.  Pathology  and  more 
especially  Bacteriology  have  been  given  ample  consideration. 

An  intimate  acquaintance  with  the  needs  of  the  physician,  while  teach- 
ing Diseases  of  Children  at  the  New  York  Post-graduate  Medical  School 
and  Hospital,  has  proven  the  value  of  photographic  and  color  plates  to 
express  the  true  nature  of  disease.  For  this  reason,  in  almost  every  article, 
I  have  used  liberally,  clinical  and  pictorial  illustrations  of  cases. 

Due  credit  has  been  given  in  the  text  for  some  photographs  loaned  to 
me.  The  staffs  in  the  various  hospitals  have  given  me  liberal  assistance 
and,  in  many  instances,  practical  advice. 

I  desire  to  acknowledge  the  kind  assistance  of  Drs.  D.  Ashley,  H.  T. 
Brooks,  Wolf  Freudcnthal,  Archibald  E.  Isaacs,  Herman  Jarecky,  M.  D. 
Lederman,  and  L.  S.  Manson  for  suggestions  in  the  special  articles  per- 
taining to  orthopedics,  pathology,  ear,  eye,  throat,  and  nervous  systems. 

Most  of  the  original  half-tones  and  colored  illustrations  were  made 
by  Mr.  Henry  C.  Lehmann.  I  am  especially  indebted  to  him  for  pains- 
taking care  in  the  illustrations  of  diphtheria  and  scarlet  fever  made  for  me 
at  the  bed-side  of  cases  in  the  hospital.  I  desire  to  acknowledge  the  liber- 
ality and  uniform  courtesy  which  my  publishers  have  extended  to  me. 

Louis  Fischer. 

65  East  Ninetieth  Street, 
New  York  City. 


CONTENTS. 


PAET   I. 

Development    and    Hygiene    of    the    Infant. 
Diagnostic  Suggestions. 

CHAPTER  PAGE 

I. IXFAXCY   AXD   CHILDHOOD 1 

The  new-born  infant;  infancy,  childhood. 

II. — The  Development  of  the  Various  Senses 2 

Reflex  actions;  sighing;  urine;  suckling  or  nursing;  supix)rting  the 
head;  sitting;  playing;  stamping  with  the  feet;  the  first  attempts 
at  walking;  laughing;  kissing;  tears;  memory;  taste;  touch;  voice 
sounds;  very  late  speaking;  sudden  loss  of  speech  due  to  paralysis. 

III. — The  Development  of  the  Body 5 

Growth  and  height;  dentition. 

IV. — Diagnostic  Suggestions   9 

The  pulse- rate;  respirations;  temperature;  eye;  gestures;  cry; 
tongue;  throat;   sleep;   the  value  of  X-ray  in  diagnosis. 

V. — General  Hygiene    of  the  Infant 16 

Hygiene  of  the  mouth  and  teeth;  management  of  the  navel;  the  um- 
bilical cord;  vernix  caseosa;  bathing  the  baby;  clothing;  the  nur- 
sery; ventilation;  when  to  take  an  infant  out-of-doors;  the  nurse- 
maid; method  of  heating  the  nursery;  light:  furniture;  bed  and 
pillow;  proper  training  of  bowels  and  bladder;  hygiene  of  the  nervous 
system;  exercise. 


PAET  IT. 

Abnormalities  and  Diseases  of  the  Newly-born. 

I. — Premature  Infants   24 

IManagcmcnt  of  a  premature  infant;  method  of  feeding;  premature 
birth;  artificial  feeding. 

II. — I'ROPHYLAXIS  AND  TREATMENT  OF  THE  EyES   IN  THE  NeW-BORN 32 

III. — Diseases  and  Malformations  of  the  Umbilicus 33 

Granuloma;  diphtheritic  omphalitis;  dangers  incident  to  careless- 
ness in  handling  the  navel;  septic  omphalitis;  Meckel's  diverticulum; 
congenital  obliteration  of  the  bile  ducts. 

IV. HEMORRHAGIC   DISEASES   OF   THE   NeWLY-BORX 37 

Spontaneous  haemorrhage;  umbilical  haemorrhage;  gastro-intestinal 
hflemorrhage. 

(Vii) 


Viii  CONTENTS. 

CHAPTER  PAGE 

V. — ^Injubies  in  the  New-born 40 

Fractures;  obstetrical  paralysis. 

VL — Asphyxia  Neonatorum  42 

VII. — FcETAL  Ichthyosis   46 

V^lll. — Inflammatory  and  Noninflammatory  Conditions 48 

■  Icterus  neonatorum ;  sclerema  neonatorum ;  liiEmoglobinuria  neona- 
torum; acute  fatty  degeneration  of  the  new-born;  mastitis  neona- 
torum; erysipelas  in  the  new-born;  tuberculosis  in  the  new-born; 
peritonitis  in  the  new-born;   pemphigus  neonatorum. 

IX. — Abnormalities  and  Congenital  Malformations 53 

Angcioma;  harelip;  cleft  palate;  tongue-tie;  congenital  adenoids; 
protrusion  of  the  ears;  abnormalities  of  the  air  passage;  congenital 
stenosis  of  the  larynx;  prominent  sternum;  depressed  sternum; 
haematoma  of  the  sterno-mastoid;  cephalha!nuitoma;  caput  succeda- 
neum;  congenital  cyst  of  the  kidney;  congenital  sacral  tumor;  con- 
genital malformations  of  the  rectum. 

PAET    III. 
Feeding  in  Health  axd  Disease. 

I. — Breast-milk   and  Wet-nursing 61 

Colostrum;  breast-milk;  the  mammary  glands;  breast  feeding;  scanty 
breast-milk  requiring  mixed  feeding;  disturbances  during  breast  feed- 
ing; immunity  conferred  by  breast-milk;  additional  foods  during  the 
nursing  period;  diet  of  a  nursing  mother;  wet-nurse;  weaning  and 
feeding  from  one  year  to  fifteen  months;  management  of  woman's 
nipples;   proteid  indigestion. 

II. — Cows'  Milk 99 

Chemical  examination:  Fat;  sugar;  proteids;  alkalies;  cream,  and 
top-milk. 

111. — Home  Modification   of  Milk 139 

Bottle-feeding  or  liand-feeding;  diet  for  a  chikl  from  one  year  to 
fifteen  montlis;  diet  for  a  child  from  eighteen  months  to  three  years; 
diet  for  a  child  from  the  third  to  the  tenth  year;  feeding  of  delicate 
or  sick  children;  substitute  feeding;  feeding  bottles:  nipples;  sterili- 
zation; pasteurization;  caloric  method  of  infant- feeding;  milk 
idiosyncrasies. 

IV. — Laboratory  Modification  of  Milk 173 

y. — Other   Substitute   Foods 182 

Coat's  milk;  buttermilk  feeding;  Bulgarian  milk;  Laliman's  vege- 
tiible  milk;  Gaertner  mother  milk;  Backhaus's  milk;  condensed  milk. 

VI. — Proprietary   Infant   Foods 103 

Nestle's  food;  Horlick's  malted  milk;  milkine;  cereal  milk;  Wam- 
pole's  milk  food;  Imperial  Cranum;  Eskay's  albumenized  food; 
Mcllin's  food;  Just's  food;  peptogenic  milk  powder. 

VII. — Concentrated  Preparations  of  Albumen 205 

VIII. — Additional  Nutrients  and  Stimulants 209 

IX. — Infants'    Weight 216 


CONTENTS.  ix 

PAET  IV. 

Diseases  of  the  Mouth^  (Esophagus^  Stomach, 

Intestines,  and  Eectum,  and  Disorders 

Associated  with  Improper  Nutrition. 

CHAPTEE  PAGE 

I. — Diseases  of  the  Mouth 222 

Stomatitis;  stomatitis  catarrhalis ;  stomatitis  aphthosa;  Bediiar's 
aphthae;  parasitic  stomatitis;  croupous  stomatitis;  syphilitic  stoma- 
titis; stomatitis  gangrenosa;  epithelial  desquamation;  congenital 
hypertrophy  of  the  tongue;  bifid  tongue;  bifid  uvula;  glossitis; 
ranula;  alveolar  abscess. 

II. — Diseases  of  the  CEsophagus 2.34 

Acute  oesophagitis;  croupous  or  diphtheritic  oesophagitis;  retro- 
oesophageal  abscess;  foreign  bodies  in  the  oesophagus. 

III. — Diseases  of  the  Stomach 236 

Acute  gastric  catarrh;  spasm  of  the  pylorus;  hypertrophic  pyloric 
stenosis;  gastro-duodenitis;  chronic  gastritis;  acute  dilatation  of 
the  stomach;  gastroptosis;  ulcer  of  the  stomach;  cyclic  vomiting; 
dyspeptic    astlima. 

IV. — Diseases  of  the  Intestines 260 

The  intestines;  bacteria  of  the  intestines;  diarrhoea;  ileo-colitis; 
chronic  constipation;  intestinal  colic;  acute  intestinal  indigestion; 
chronic  intestinal  indigestion;  acute  milk  infection;  subacute  milk 
infection;  appendicitis;  psevido-appendicitis;  intussusception;  um- 
bilical hernia;  worms. 

V. — Diseases  of  the  Rectum 331 

Fissure  of  the  anus;  simple  catarrhal  proctitis;  croupous  proctitis; 
ulcerative  proctitis;  haemorrhoids;  ischio-rectal  abscess;  prolapsus 
ani. 

VI. — Disorders   Resulting  from   Improper   Nutrition    (Disturbed  Meta- 
bolism ) 335 

Scurvy;  rachitis;  athrepsia  infantum. 


PART   V. 

Diseases  of  the  Heart,  Liver,  Spleen,  Pancreas, 
Peritoneum,  and  Genito-urinary  Tr.\ct. 

I. — Introductory    3G1 

II. — Diseases  of  the  Heart 366 

Iloflcx  symptoms  of  the  lieart,  tachycardia,  bradycardia;  pulmonary 
stenosis;  persistence  of  the  ductus  arteriosus  Rotalli;  endocarditis; 
malignant  endocarditis;  pericarditis;  tuberculosis  of  the  pericar- 
dium; hydropericardium;  myocarditis. 


X  CONTENTS. 

CHAPTEK  PAGE 

III. — Diseases  of  the  Lr^e 381 

Jaundice;  acute  congestion  of  the  liver;  functional  disorders  of  the 
liver;  displacement  of  the  liver;  descended  liver;  amyloid  degenera- 
tion; fatty  liver;  cirrhosis;  focal  necrosis;  subphrenic  abscess. 

IV. — Diseases  of  the  Spleen  and  Pancreas 386 

V. — Diseases  of  the  Peritoneum 388 

Acute  peritonitis;  chronic  peritonitis;  tuberculous  peritonitis; 
ascites. 

VI. — Diseases  of  the  Genital  Organs 395 

Hernia;  hydrocele;  adherent  prepuce;  phimosis;  paraphimosis; 
hypospadias;  epispadias;  ciyptorchidism;  orchitis;  vulvo-vaginitis; 
simple  vaginitis;  gonorrhceal  vaginitis;  vicarious  menstruation; 
menstruation  praecox. 

VIT. — Diseases  of  the  Kidney  and  Bladder 405 

Acute  nephritis;  secondary  nephritis;  perinephritis;  pyelitis;  ectopia 
vesicae  congenital  is;  indicanuria ;  acetoniiria;  diacetonuria;  jjj'uria; 
diabetes  insijudus;  lordotic  albuminuria;  hiematuria ;  haemoglo- 
binuria;  glycosuria;  diabetes  mellitus;  colicystitis;  vesical  calculi; 
acute  cystitis;  chronic  cystitis;  enuresis. 

PAET    VI. 

Diseases  of  the  Eespiratory  System. 

I. — Diseases  of  the  Nose  and  Throat 425 

Acute  nasal  catarrh ;  naso-pharyngeal  catarrh ;  foreign  bodies  in  the 
nose;  tonsillitis;  follicular  tonsillitis;  croupous  tonsillitis;  ulcero- 
membranous tonsillitis;  phlegmonous  tonsillitis;  chronic  hypertrophic 
tonsillitis;  tuberculosis  of  the  tonsils;  adenoid  vegetation;  retro- 
pharyngeal abscess;  spasmodic  laryngitis;  foreign  bodies  in  the 
larynx;  coughs  of  reflex  origin. 

II. — Diseases  of  the  Bronchi,  Lungs,  and  Pleura 450 

Broncho-pneumonia;  pulmonary  gangrene;  pleurisy;  dry  pleurisy; 
pleurisy  with  elTusion;  empyaema. 

PAET    VII. 

The  Infectious  Diseases. 

I. — Fever 472 

II. — Influenza  479 

III. — Pertussis  (  Whooping-cough  )    48G 

IV. — Pneumonia   (Lobar) .     Tubercular  Pneumonia 497 

V. — Acute  Tuberculosis.     Chronic  Pulmonary  Tuberculosis 516 

VI. — Acute    Diphtheria.     Chronic    Diphtheria.      Intubation.      Tracheo- 
tomy.   Diphtheroid.    Pseudo-Diphtheria 539 

VII. — Rubella   (German  Measles) 622 

VIII. — Measles  (Morbillt,  Rubeola) 628 

IX. — Scarlet  Fever  (  Scarlatina  ) 643 


CONTEXTS.  xi 

CHAPTER  PAGE 

X. — Duke's  Disease    { Fourth   Disease) 674 

XI. — Varicella  (  Chicken  Pox  ) , 676 

XII. — Variola  axd  Vaccination , 680 

XIII.— Typhoid  Fever 689 

XIV. — Erysipelas 702 

XV.— Malaria 706 

XVI.— Syphilis  716 


PART   VIII. 

Diseases  of  the  Blood^  Glands  or  Lymph-nodes, 

AND  Ductless  Glands. 

I. — Introductory 726 

II. — Diseases  of  the  Blood 733 

Anaemia;  splenic  anaemia;  secondary  anaemia;  pernicious  anaemia; 
leukaemia;  pseudo-leuksemic  anaemia;  chlorosis. 

III. — ^Acute  Rheumatism 740 

Muscular  rheumatism;  torticollis;  purpura;  purpura  rheumatica; 
lithaemia;  haemophilia. 

IV. — Diseases  of  the  Glands  or  Lymph  Nodes 753 

Status  lymphaticus;  acute  adenitis;  chronic  adenitis;  tubercular 
adenitis;  mumps. 

V. — Diseases  of  the  Ductless  Glands 760 

Cretinism;  exophthalmic  goiter ;  acute  thj'roiditis ;  abnormality  of  the 
thyroid;  diseases  of  the  thymus  gland;  diseases  of  the  adrenal  glands; 
Addison's  disease. 


PART  IX. 

Diseases  of  the  Nervous  System. 

I. — Fontanel  775 

Percussion  of  the  skull;  the  brain;  reflexes. 

II. — Convulsions   781 

Headaches;  spasmus  nutans;  stammering  and  stuttering;  chorea; 
hysteria;  multiple  neuritis;  pavor  noeturnus;  masturbation. 

III. — Tetany  798 

Tetanus;  epilepsy;  myelitis;  spina  bifida;  spinal  paralysis;  hydro- 
cephalus; meningocele;  encephalocele;  cyclops;  porencephaly. 

IV. — Tubercular    Meningitis 819 

Cerebrospinal  meningitis;  acute  pachymeningitis;  cerebral  paralysis; 
pleuroplegia;  psendoliyijcrtrophic  paralysis;  cerebral  abscess;  aliilia 
idiopathica  ;  idiocy  and  imbecility;  infantile  amaurotic  family  idiocy; 
concussion  of  the  brain;    insolation. 


xii  CONTENTS. 

PART  X. 

Diseases  of  the  Ear,  Eye,  Skin,  and  Abnormal 
Growths. 

CHAPTE3  PAGE 

I. — Diseases  of  the  Ear 85 1 

Acute  catarrhal  otitis  media;  mastoid  operation  on  infants  and  chil- 
dren; foreign  bodies  in  the  ear;  thrombosis  of  cerebral  sinuses. 

II. — Diseases  of  the  Eye 801 

Acute  catarrhal  conjunctivitis;  pneumococcus  ophthalmia;  pus  infec- 
tion of  the  conjunctiva;  purulent  ophthalmia;  membranous  conjunc- 
tivitis; granular  ophthalmia;  blepharitis;  hordeolum;  plilyctenular 
conjunctivitis. 

III. — Diseases  of  the  Skin 869 

Eczema;  eczema  rubrum;  local  erythema;  erythema  intertrigo; 
naevus;  tine.a  tonsurans;  verruca;  urticaria;  impetigo;  pediculosis; 
miliaria  papulosa;  miliaria  rubra;  svidamina;  lentigo;  seborrhoea ; 
furuncle;  chronic  pemphigus;  burns;   symmetrical  gangrene;   scabies. 

IV. — Abnormal  Growths   884 

Spindle-cell  sarcoma;  carcinoma;  angeioma;  lipoma;  enchondromata ; 
papillomata. 

PAET  XI. 

Diseases  of  the  Spine  and  Joints. 

Diseases  of  the  Spine  and  Joints 890 

Pott's  disease;  flat  foot;  latei-al  curvature  of  the  spine;  morbus 
coxarius;  congenital  dislocation  of  the  hip;  knee-joint  disease;  dis- 
eases of  the  ankle-joint  and  tarsus;  wrist-joint  and  elbow- joint  dis- 
ease; acute  arthritis. 


PAET  XII. 

Miscellaneous. 

I. — Dietary    905 

II. — The  Adulteration  of  Milk 912 

III. — The  Examination  of  the  Gastric  Contents 915 

IV.— Urine   917 

V. — Bacteriological  Memoranda  928 

VI. — An,ti:stiietics  in  Children 930 

VII. — Disinfection  934 

VIII. — The  Administ?.ation  of  Drugs 930 

IX. — Local  Remedies 937 

X. — Rectal  Medication 939 

XI. — Prescriptions  for  Various  Diseases 941 

Hypodermic  medication. 

XII.— Table  of  Doses 944 


LIST   OF    ILLUSTEATIONS. 


FIGURE  PAGE 

1.  A,  Tympanic  cavity.     B,  Otic  ganglion.     C,  Tooth.     D,  Internal  carotid.     E, 

Tympanic  branch.  F,  Auriciilo-tomporal  nerve.  G,  Auricular  branch 
of  auriculo-tcmporal  nerve.  The  dotted  line  connecting  B  and  C  repre- 
sents the  inferior  dental  nerve 6 

2.  Two  middle  lower  incisors.     Nine  to  sixteen  months 8 

3.  Four  upper  incisors.     Nine  to  sixteen  months 8 

4.  Two  lateral  lower  incisors  and  four  molars.     Thirteen  to  seventeen  months.  8 

5.  Four  canines.     >Sixteen  to   twenty-one   montiis 8 

6.  Twenty  milk  teeth.     Twenty-three  to  thirty-six  months 8 

7.  Tongue  depressor 14 

8.  Bath  thermometer   18 

9.  Proper  shaped   shoe   for   infant 20 

10.  Schering's   formaline   lamp 22 

1 1.  Incidjator    25 

12.  Feeder  for  premature  infants 29 

13.  Funnel  and  catheter  for  forced  feeding 29 

14.  Weight  chart    30 

15.  Case  of  omphalocele    34 

16.  Appearance  of  abdomen  four  weeks  after  treatment 34 

17.  Diagram  illustrating  effects  of  persistence  of  the  omplialomesenteric  duct, 

and  the  formation  of  the  so-called  diverticulum  tumor 34 

18.  19.  Ribemont's  tube  for   inflating  the   lungs 44 

20.  A  case  of  angeioma 53 

21.  Harelip  nipple 54 

22.  Congenital   cj'stic   kidney .    58 

23.  Congenital   sacral  tumor 59 

24.  Colostrum  corpuscles  in  a  drop  of  milk 61 

25.  Heeren's  Pioscop,   for  optical   milk   test 66 

26.  Specimen  of  breast-milk  from  a  young  mother,  17  years  old 68 

27.  Specimen  of  breast-milk,  illustrating  very  high  fat,  causing  gastric  disturl)- 

ance    68 

28.  Showing  a  drop  of  milk  under  the  microscope 75 

29.  Drop  of  breast-milk  from  a  very  anaemic  woman 75 

30.  Holt's  milk  test  set,  for  testing  human  milk 76 

31.  Breast-milk  taken  from  a  wet-nurse  during  menstruation 85 

32.  Pear-shaped   breasts,   best   adapted    for   nursing 89 

33.  Ideal    feeding   cup 91 

34.  Nipple-shield  for  relief  of  (endcr  nijjpbs 94 

35.  36.  Breast-pump     95 

37.  Centrifugal  testing  machine,   for  handpowcr 117 

38.  Graduated   cream   gauge 118 

39.  Marchand's  tube    118 

40.  Feser's   lactoscope    118 

41.  Cows'  milk,  showing  fat-globules 119 

42.  Woodward's  burette  for  estimating  proteids 124 

43.  Chapin  cream  dipper 1,32 

44.  Materna    home    modifier 150 

45.  Mitchell's  milk  modifying  gauge 152 

(xiii) 


XIV 


J. 1ST  OF  ILLLSTRATIOXS. 


FIGURE  PAGE 

4ii.  Author's    clioico    of    fc'i'diiig-lxjttlo 157 

47.  Bottle  warmer 157 

48.  Bottle-bruish    158 

49.  Anticolic  nipple    158 

50.  Xipple-sterilizer     159 

51.  Arnold  steam   sterilizer 164 

52.  Weight  chart  of  M.  L 171 

53.  Enterprise   juice   extractor 211 

54.  The   Chatillon   scale 216 

55.  Cliart  showing  gain  in  weight  of  babj'  Kobert  M.  F 218 

56.  Chart  showing  gain  in  weight  of  baby  J.  S 219 

57.  Chart  showing  gain  in  weight  of  baby  fed  on  Eskay's  food  after  third  week.   219 

58.  Chart  showing  gain  in  weight  of  baby  A 220 

59.  Chart  showing  gain  in  weight  of  baby  D.  S 220 

59a.  Case  of  sprue   (Thrush)   due  to  faulty  hygiene  of  the  mouth 224 

60.  Case  of  stomatitis  gangrenosa  (noma)  following  scarlet  fever 230 

61.  Hinged  bucket  235 

62.  Infant's  stomach.     Actual  size.     From  a  case  of  malnutrition 240 

63.  Infant's  stomach.     Actual  size.     Died  suddenly  from  convulsions 240 

64.  Infant's  stomach.     Capacity,  10  ounces.     Age  of  child,  eleven  months 241 

65.  Infant's  stoma.ch.     Capacity  of  measurement,  14  ounces 241 

66.  Drawing  from  a  case  of  acute  dilatation  of  the  stomach 253 

67.  Translumination  of  the  stomach  with  the  aid  of  a  gastrodiaphane,  in  a  case 

of  gastroptosis.      ( Colored )    255 

68.  a,  Normal*  position  of  stomach.     6,  Position  of  stomach  in  a  case  of  gas- 

troptosis     256 

69.  Bacterium  coli  commune 267 

70.  Bacterium  lactis  aerogcnes ^75 

71.  Chart  of  death-rate  from  diarrhoea  in  Manhattan  and  Bronx,  1S98,  1899.  .  .  278 
71a.  Chart  of  death-rate  from  diarrhoea  in  Manhattan  and  Bronx,  1900,  1901.  .  279 
716.  Chart  of  death-rate  from  diarrhoea  in  Manhattan  and  Bronx,  1902,  1903.  .   280 

72.  Bacillary  diphtheria  of  the  colon  or  diphtheritic  colitis.      (Colored) 281 

73.  Croupous  enteritis,  diphtheritic  colitis 282 

74.  Dysentery.     Baby  ^I.,  thirteen  months  old.     Seen  fourth  day  after  illness. 

Serum  injected   283 

75  to  80.  Abnormalities  of  the  sigmoid  flexure 289 

81.  Rubber  bulb  syringe 290 

82.  Irrigator,  with  tube  attached  and  hard  rubber  points 291 

83.  Soft  rubber  rectal  tube  for  irrigating  the  colon 291 

84.  A  case  of  acute  milk  poi.soning 303 

85.  Exact  size  of  catheter  xised  for  irrigating  a  very  yoimg  infant 307 

86.  Stomach-washing.     Introduction  of  the  catheter 308 

87.  Stomach-washing.     Syphoning  off  the  gastric  contents 309 

88.  Mechanism  of  intussusception 322 

89.  Fever  chart  in  a  case  of  intussusception 323 

90.  Umbilical  hernia 326 

91.  Umbilical  hernia  truss 326 

92.  Case  of  hydrancephaloid    (spurious   hydrocephalus) 342 

93.  Same  child,  two  years  later 342 

94.  A  case  of  spurious  hydrocephalus,  illustrating  marked  frontal  and  parietal 

protuberances    343 


LIST  OF  ILLUSTRATIONS,  XV 

FIGURE  PAGE 

95  to  98.  Illustrating  rachitic  erosions  of  the  permanent  teeth 345 

99.  Rachitic  ribs 346 

100.  Case  of  rickets,  showing  enlarged  spleen,  also  pendulous  belly. 347 

101.  Five-weeks-old  fracture  of  the  humerus  in  a  rachitic  child  li/l>  years  old.  .  .  348 

102.  Rickets,  longitudinal  section  through  ossification  junction  of  upper  diaphe- 

seal  end  of  femur 349 

103.  A  severe  type  of  rickets,  witli  enlargement  of  both  condyles  of  the  femur.  .  350 

104.  Rickets,  showing  beaded  ribs  and  an  enlarged  pendulous  belly 352 

105.  Rickets,  showing  beaded  ribs 353 

106.  Rachitic  kyphosis   (spine) .     Front  view 354 

107.  Rachitic  kyphosis   (spine) .     Back  view,  same  child 354 

108.  Athrepsia  infantum    358 

109.  Athrepsia  infantum    359 

110.  Apex  beat  in  a  very  young  infant 362 

111.  Apex  beat  in  a  child  about  6  years  old 362 

112.  Apex  beat  in  a  child  about  12  years  old 362 

113.  Irregular  pulse,  low  tension,  from  a  case  of  mitral  regurgitation 363 

1 14.  Natural  size  of  Bowles  stethoscope  for  examining  children 364 

115.  Convenient  stethoscope  for  children 364 

116.  Case  of  pulmonary  stenosis — congenital — blue  baby 369 

117.  Child  Avith  persistence  of  the  ductus  arteriosus  Botalli 371 

118.  Case  of  tubercular  peritonitis  complicated  by  tubercular  empj'isma 391 

119.  Gonococcus.     (Colored)    401 

120.  Nephritis  complicating  diphtheria 407 

121.  Case  of  pyelonephritis 413 

122.  Extrophy  of  the  bladder,  and  prolapse  of  anus 416 

123.  Atomizer   426 

124.  Lefferts'  posterior  and  anterior  nasal  syringe 427 

125.  Lenox  nasal  douche 428 

120.  Graduated  douche,  suitable  for  older  children 428 

127.  Vincent's  bacillus  found  in  ulcerative  angina 433 

128.  Throat  spray ' 434 

129.  Throat  ice-bag   434 

130.  The  Baginskj'  tonsillotome 436 

131.  The  Mackensie  tonsillotome 436 

132.  Typical  adenoid  face  in  a  cretin 439 

133.  Digital  method  of  exploring  the  rhino-pharynx  for  adenoids 440 

134.  Temperature  chart  from  a  case  of  retropharyngeal  abscess 443 

135.  Oil  atomizer 445 

136.  Steam  atomizer   446 

137.  Croup  kettle  447 

138.  Diplococcus  pneumonite    ( pneumococcus ) .      (Colored) 457 

139.  Purulent      (suppurative)      bronchitis,     peribronchitis,     and     peribronchial 

broncho-pneumonia  in  a  child  fifteen  months  old 458 

140.  Diphtheria    (septic)   broncho-pneumonia.     Louis  B.,  age  three  years 459 

141.  Diagram  for  pneumonia  jacket  opened  at  side 461 

142.  Diagram  for  pneumonia   jacket  opened  at  front 461 

143.  Fever  curve  in  a  case  of  dry  pleurisy 463 

144.  Fever  curve  in  a  case  of  pleurisj',  with  efl'usion 405 

145.  Diagi-ammatic    illustration  of   heart   and   lungs    in    a   left-sided    pleuritic 

effusion 400 


xvi  LIST  OF  TLLl'STRATIONS. 

FIGTRE  PAGE 

140.  Illustrating  a  severe  localized  right-.sided  empyaema 4RR 

147.  James's  apparatus  for  expanding  the  lungs  in  empj-sema 470 

148.  Influenza  bacilli.      ( Colored) 479 

149.  Case  of  influenza  pneumonia  in  a  child  I'iglit  iiiontlis  old 481 

150.  Case  of  influenza  pneumonia  in  a  child  two  years  old 483 

151.  Focal  metastatic  luTcmatogcnous  streptococcus — pneimionia  following  angina. 

( Colored )     498 

152.  Croupous   pneumonia    498 

153.  Case  of  influenza  and  pneumonia 500 

154.  Fever  curve   in   pleuropneumonia 501 

155.  Case  of  cerebral  pneumonia 502 

156.  Cerebral  pneumonia,  with  high  temperature  and  marked  decrease  in  tem- 

perature after  cold  baths 504 

157.  Lobar  pnevimonia  of  a  severe  type 508 

158.  Tubercle  bacilli  and  micrococcus  tetragsnus   (sputum).      (Colored) 520 

159.  Tuberculosis— horizontal  section  through  lower  lobe  of  right  lung  of  two- 

year-old  child   . 521 

IGO.  Acute  pulmonary  miliary  tuberculosis  (cut  surface  of  the  lung) 523 

161,  Fever  cui've  during  the  early  period  of  chronic  pulmonary  tviberculosis 536 

162.  Temperature  curve  during  the  fifth  month 536 

103.  Chronic  nodular  tuberculous  broncho-pneumonia 537 

164.  Diphtheria  or  Klebs-Loeffler  bacilli;   smear  preparation  from  tonsillar  de- 

posit.     ( Colored )    544 

165.  True  and  false  diphtheria 545 

166.  Section  from  an  inflamed  uvula  covered  with  a  stratified  fibrinous   mem- 

brane, from  a  case  of  diphtheritic  croup  of  the  pharyngeal  organs 547 

167.  Case  of  nasal  diphtheria 552 

168.  Septic  type  of  diphtheria,  complicated  by  myocarditis 553 

169.  Broncho-pneumonia  complicating  diphtheria 554 

170.  Pneumonia  complicating  diphtheria 559 

171.  Temperature  chart  from  a  case  of  diphtheria  complicated  by  broncho-pneu- 

monia  (step-ladder  type  of  fever) 560 

172.  Temperature  chart  from  a  case  of  diphtheria  complicated  by  lobar  pneu- 

monia    561 

173.  Temperature   chart  from  a   case  of   diphtheria   complicated   by  otitis   and 

meningitis 562 

174.  Glass  aseptic  antitoxin  syringe 570 

175.  Temperature  chart  from  a  case  of  diphtheria,  showing  the  specific  effect  of 

antitoxin  on  the  temperature 572 

176.  Temperature  chart  from  a  case  of  diphtheria,  showing  effect  of  dry  antitoxin  574 

177.  Introducer  with  tube  attached 584 

178.  Introducer  with  tube  and  detached  obturator 584 

179.  Introducer  holding  foreign  body  tube 584 

180.  Extubator   585 

181.  Built-up  tubes  for  granulation  tissue 585 

182.  Fischer's  corrugated  rubber  tube,  to  be  used  for  intra-laryngeal  medication 

in  chronic  stenosis    (recurring  stenosis) 585 

183.  The  mummy  bandage,  showing  child  in  proper  position  for  the  dorsal  method 

of  intubation 586 

184.  Intubation.     First  step  in  the  operation 587 

185.  Intubation.     Second  step  in  the  operation 587 


LIST  OF  ILLUSTKATIOXS.  xvii 

FIGUBE  PAGE 

186.  Extubation.     First  step  in  the  operation 589 

187.  Extubation.     Second  step  in  the  operation 589 

188.  Chart  showing  laryngeal  diphtheria  complicated  by  broncho-pneumonia.  .  .  .  591 

189.  Gavage — method  used  in  forced  feeding  at  Willard  Parker  Hospital 594 

190.  Casselberry  method  of  feeding ,. 595 

191.  Temperature  chart  from  a  case  of  diphtheria:    croup,  intubation 596 

192.  Laryngeal  diphtheria   604 

19.3.  Diphtheria — laryngeal  stenosis  requiring  intubation 611 

194.  Temperature  chart  from  a  case  of  larjngeal  diphtTieria 613 

195.  Silver  trachea  cannula  used  in  tracheotomy 616 

196.  Hard  rubber  trachea  cannula 616 

197.  Temperature  chart,  case  of  rubella 625 

198.  A  case  of  malignant  measles,  complicated  by  diphtheria  and  ending  with 

empyaema   635 

199.  Temperature  chart   from   a  case  of  measles   complicated  by  broncho-pneu- 

monia        636 

200.  Temperature  chart  from  a   case  of   measles   complicated  by  broncho-])iieu- 

monia 637 

201.  Desquamation  of  left  side  of  chest  in  a  case  of  scarlet  fever 648 

202.  Septic  scarlet  fever  with  myocarditis,  suppurative  arthritis,  double  purulent 

otitis,  general  pyaemia 050 

203.  Chart  showing  temperature  and  complications  in  a  case  of  scarlet  fever.  .  .  .  653 

204.  Septic  nephritis  657 

205.  Drop  of  urine  from  a  case  of  post-scarlatinal  nephritis 658 

206.  The  heart  in  a  case  of  scarlet  fever 659 

207.  Post-operative  scarlatinoid  erythema 662 

208.  Coffey's  glass  apparatus  for  hypodermic  saline  injections 666 

209.  Temperature  chart  from  a  case  of  scarlet  fever  treated  with  antistrepto- 

coecus  serum   609 

210.  Method  of  nasal  syringing  employed  in  the  scarlet  fever  Avard  of  the  River- 

sido  Hospital  670 

211.  Temperature   curve   in  varicella 677 

212.  Erysipelas  following  varicella '. 679 

213.  Fatal  smallpox  in  an  unvaccinated  four-weeks-old  infant 680 

214.  Temperature  curve  in  variola 682 

215.  Smallpox  in  a  child  that  was  vaccinated  during  the  incubation  period 083 

210.  Mild  discrete  smallpox  in  an  unvaccinated  girl 684 

217.  Accidental  vaccination  on  the  cheek 687 

218.  Typhoid  infantum  in  a  two-year-old  boy 691 

219.  Stages  in  Widal  reaction 694 

220.  Typhoid  fever.     Severe  haemorrhages 696 

221.  Ectogenous  streptococcus  infection.      (Colored) 702 

222.  Fever  curve  in  facial  erysipelas 703 

223.  Fever  curve  in  phlegmonous  erysipelas 704 

224.  Malaria  plasmodia,  tertian  type.      ( Colored) 707 

225.  Malaria  plasmodia,  tropical  form.      (Colored) 707 

226.  Tertian  fever   (intermittent  fever) 708 

227.  Quartan  fever  (double  tertian) 709 

228.  .'Estivo-autumnal  fever  (mild  type) 710 

229.  Spirocliaete  pallida  and  spirochaete  refringens  from  a  case  of  syphilis 718 

230  to  233.  Ryphilitie  teeth '. 722 

234.  Malignant  purpura,  complicating  nasal  <liphtlieria 748 


xviii  LIST  OF  ILLI'STRATIONS. 

FIGCRE  PAGE 

235.  Case  of  cervical  adenitis  in  wliicli  a  positive  von  l'ii([iiet  reaction  appeared.  75() 

236,  237,  238.  Sporadic    cretinism     761 

239,  240,  241.  Sporadic  cretinism    765 

242  to  249.  A  case  of  cretinism 7(U),  707,  7(iS,  769 

250.  Sagittal  section  of  normal  liead  of  seven  and  one-lialf  months'  fcetus 776 

251.  Normal  head  as  seen  from  above 776 

252.  Sagittal  section  of  normal  head 776 

253.  Sagittal  section  of  head  immediately  after  normal,  easy  labor 776 

254.  255.  Sagittal  section  of  head  immediatelj'  after  laljor 777 

256.  Sagittal  section  of  head  of  infant  six  days  old 777 

257.  Tetany    798 

258.  Case   of   spina   billda 808 

259.  Poliomyelitis     810 

260.  Infantile   paralysis,   with   atropjiy   and    impaired   growtli   of   the   riglit    leg, 

and  drop-foot    811 

261.  Infantile  paralysis,  with  atrophy  of  the  right  leg 811 

262.  Infantile   paralysis    813 

263.  Hydrocephalic    ealvarium     (or    skull-cap),    widely    gaping    fontanels    and 

sutures     815 

264.  265.  Case  of   chronic   internal   hydrocephalus    816 

266.  Case    of    encephalocele     817 

267.  Tuberculous    spinal    meningitis     820 

268.  Case  of  tuberculous  meningitis,  well  marked,  ending  fatally    822 

269.  Anatomical  illustration,  showing  the  place  best  adapted  for  lumbar  punc- 

ture         828 

270.  Lumbar   puncture   needle    829 

271.  Lumbar  puncture  made  between  fourth  and  fifth  lumljar  vertebne 830 

272.  Infantile    cerebral    paralysis 836 

273.  Pseudohypertrophic    paralysis    840 

274.  275,  276.  A  case  of  pseudohypertrophic   paralysis    841 

277.  Facial    Paralysis    following   mastoid   operation    842 

278.  Congenital     idiocy 846 

279.  280,281,282.  Imbecile     (Louie    W.)      847,  848 

283.  Insolation    ( heat  stroke )     852 

284.  Complication  of  scarlet  fever  seen  in  my  service  at  Riverside  Hospital   ....  855 

285.  Ear    syringe     856 

286.  A  common  type  of  acute  mastoid  inllammation  following  intluenza    859 

287.  Trachoma,  showing  round,  opaque  bodies  in  upper  and  lower  lids   800 

288.  Method    of   everting   eyelid    867 

289.  Case  of  gangrene  following  lobar  pneumonia    882 

290.  Spindle-cell    sarcoma    885 

291.  Anterior  view  of  the   tumor    886 

292.  Enchondroniata  involving  the  thumb  and  index  fing:^r    888 

293.  Pott's    disease     890 

294.  Pott's  disease,  case  of  Harry  F 89.5 

295.  296.  Schoolgirl,  shoMing  lateral  curvature  of  the  sjsiiie.  due  to  faultv  posi- 

tion      ; \ " 897 

297,  298.  Tuberculous    coxitis     899 

299.  Congenital    hip    dislocation    900 

300.  Tubercular    elbow-joint    903 

301.  Urino-pyknometer,  for  estimating  the  specific  gravity  of  small   volumes  of 

urine     920 

302.  The  horismasoope  or  albumoseope    922 

303.  Gas  and  ether   inhaler    930 


LIST    OF    PLATES. 


PLATE  PAGE 

I. — Severe  case  of  scarlet  fever,  shmviiig  eruption  at  its  height ..  Frontispiece 

II. — The  Byrd-Dew  method  of  artificial   respiration 42 

III.— Fatal    fuetal    ichthyosis 46 

IV. — A  drop  of  normal  breast-milk   from   primapara 64 

y. — Microscopic   appearance   of   raw   slarch-granules 128 

VI. — Microscopic  appearance  of  starch-granules,  showing  the  effect  of  heat.   128 

VII. — Geographical   tongue,   or   epithelial   desquamation 232 

VIII. — Infant's  stomach,  one  month  old 242 

IX. — Infant's   stomach,  age  seven   months 242 

X. — Infant's  stomach,  age  eleven  months 242 

XI. — Showing  effects  of  modified   feeding 244 

XII. — Cestodes    (tape-worms)    326 

XIII. — Chronic   enlarged   tonsils.      Granular   Pharyngitis 438 

XIV. — Cutaneous  reaction  with  concentrated  and  diluted  tuberculin 532 

XV. — Severe   cutaneous   reaction.      Scrofulous   reaction 532 

XVI. — A,   Common   type   of  diphtheria.     B,   Septic  type  of  diphtheria.      C. 

Hsemorrhagic  type  of  diphtheria.     D,  Septic  type  of  diphtheria  .  .   554  ■ 

X\'II. — Morbilliform   antitoxin    rash 556 

XVIII. — Forms  of  tongue  in  scarlet  fever 648 

XIX. — Vaccinia    following   vaccination 688 

XX. — lodophilia.     Pus  reaction  of  blood 730 

XXI. — A,  Progressive  pernicious  ana>mia.     li.  Lienal    (splenic)    ani^mia.     C. 

Lienal    (splenic)    leuksemia.      D.   Acute   leukemia 734 

XXII. — Henoch's  purpura    750 

XXIII.— Front  view  of  the  foetal  skull 778 

XXIV.— Top  view  of  the  foetal  skull '. 778 

XXV. — Posterior  view  of  the   ftctal   skull 77S 

XXVI. — 1,    Meningococcus    or    diplococcus    intracellularis.      2.    Meningococcus 

intracellularis.      3.    Micrococcus    catarrhalis 824 

XXVIT. — Intracranial    injection    in    meningitis 832 

XXVIII. — Normal  mucous  membrane  of  the  middle  ear  in  the  new-born.  In- 
flammation of  the  mucous  membrane  of  the  middle  ear.  Section 
of  the  vessel   of  the   mucous  jnembrane  containing  streptococcus 

pyogenes    854 

XXIX. — X-ray  of  congenital  dislocation  of  hip 900 


(xix) 


LIST  OF  TABLES. 


TABIE  PAGE 

1.  Average  growth  of  a  child  from  tliu  first  to  the  twentieth  year 5 

2.  Dentition     7 

3.  Pulse-rate  from  the  first  to  the  fifteenth  year 10 

4.  Pulse-rate :     while  asleep;    awake,  crying 10 

5.  Respiration  while  asleep;  awake 11 

6.  Percentage  of  incubator  babies  saved  at  various  institutions 28 

7.  Comparative    frequency   of   spontaneous    haemorrhage   in   various    parts    of 

the  body   37 

8.  Properties  of  human  milk,  and  properties  of  cows'  milk 62-63 

9.  Five  analyses  of  human  colostrum  milk  made  by  Harrington 64 

10.  Analysis  of  the  first,  second,  and  third  portion  of  breast-milk 65 

11.  Comparative  analysis  of  normal  breast-milk 67 

12.  Five  analyses  of  human  milk  by  Mendel 70 

13.  Analyses  of  a  normal,  a  poor,  an  overrich,  and  a  bad  human  breast-milk.  .  71 

14.  Time  for  feeding 71 

15.  A  study  of  1000  mothers  with  reference  to  their  ability  to  nurse 80 

16.  Mortality  for  England  and  Wales,  1890-1894.     Mode  of  feeding 97 

17.  Mortality  for  London,   1890-1894 98 

18.  Deaths  due  to  diarrhoea  and  mode  of  feeding.     Cameron 98 

19.  Two  hundred  deaths.     Their  mode  of  feeding. 98 

20.  Comparative  frequency  of  tuberculosis  in  cattle,  in  the  various  states 109 

21.  Milk  preservatives  and  their  chemical  action 112 

22.  Estimation  of  fat  with  Marehand's  tube 118 

23.  Comparative  ingredients  of  woman's  milk  and  cows'  milk 120 

24.  Comparative  ingredients  of  woman's  milk  and  cows'  milk 121 

25.  Feeding  table.     Carpenter 134 

26.  Biedert's  cream  mixtures 134 

27.  Number  of  bacteria  in  unripened  and  ripened  cream 136 

28.  General  rules  for  bottle  feeding 139 

29.  Feeding  an  infant  from  one  year  to  fifteen  months 152 

30.  Feeding  from  eighteen  months  to  three  years 153 

31.  Feeding  from  three  years  to  ten  years 154 

32.  Results  on  albumin  by  heating  milk 165 

33.  Feeding  in  milk  idiosyncrasy 170 

34.  Feeding  in  milk  idiosyncrasy 172 

35.  Weight  table  of  a  laboratory-fed  infant ' 176 

36.  Percentage  of  acidity  and  difference   in   fat  of  buttermilk  and   sour   milk 

before  l)uttering   186 

37.  Analysis  of  milks 189 

38.  Comparative  ingredients  of  condensed  milk  and  woman's  milk 192 

39.  Nestle's  food  as  compared  with  woman's  jnilk 196 

40.  Horlick's  milk  as  compared  with  woman's  milk 196 

41.  -Milkine  as  compared  with  woman's  milk 197 

42.  Cereal  milk  as  compared  with  woman's  milk 198 

43.  Wampole's  milk  food  as  compared  with  woman's  milk 100 

(xxi) 


xxu 


LIST  OF  TABLES. 


TABLE  PAGE 

44.  Imperial  granum  as  compared  with  woman's  milk 199 

45.  Eskay's  food  as  compared  with  woman's  milk 201 

46.  Mellin's  food  as  compared  with  woman's  milk 201 

47.  Percentage  of  ingredients  obtained  by  various  modifications  of  milk  with 

Mellin's  food  202 

48.  Humanized  milk  as  compared  with  woman's  milk 205 

49.  Composition  of  infant  foods  as  compared  with  human  milk  by  Mendel 204 

50.  Com2)osition  of  infant  foods  as  compared  with  human  milk 204 

51.  Percentage  of  alcohol  contained  in  various  nutritive  tonics  by  Lederle  and 

Deghuee    208 

52.  Showing  gain  in  a  healthy  infant  fed  at  the  breast 217 

53.  Unorganized  ferments  present  in  the  body,  and  their  action 23S 

54.  Population,  deaths,  and  death-rate  of  children  under  five  years  of  age,  dur- 

ing June,  July,  and  August,  for  1891-1893  in   (Old)   New  York  City.  .  .   304 

55.  Population,  deaths,  and  death-rate  of  children  under  five  years  of  age  from 

1891-1903  in   (Old)   New  York  City 305 

56.  Difierential  points  between  rickets  and  Pott's  disease 355 

57.  Weight  of  the  heart 362 

58.  Classification  of  cardiac  diseases 365 

59.  Differential  points  between  hernia  and  hydrocele 396 

60.  Mortality  from  infectious  diseases  of  children  under  two  years  of  age   in 

New   York    City 475 

61.  Infectious  diseases    477 

62.  Showing  the  ratio  of  mortality  from  infectious  diseases  of  children  between 

the  ages  of  two  and  five  in  New  York  City 478 

63.  Showing  ratio   of  mortality   from   infectious   diseases   of  children  between 

the  ages  of  five  and  ten  in  New  Y'ork  City 478 

64.  Showing  percentage  of  deaths  in  children  under  ten  years  in  New  York 

City  from  1890-1902 478 

65.  Deaths  from  whooping-cough  in  children  under  fifteen  years  in   (Old)   City 

of  New  York 486 

66.  Manner  of  feeding  in  59  consecutive  cases  of  tuberculosis  among  the  poor.  .   517 

67.  Deaths  from  pulmonary  tuberculosis  in  children  under  fifteen  years  of  age 

in  New  York  City 524 

68.  Deaths  due  to  consumption  in  the  United  States,  in  children  under  fifteen 

years  during  the  census  year  1890-1001 525 

69.  Comparative  death-rate  in  children  under  fifteen  years  due  to  consumption, 

born  of  foreign  parentage 526 

70.  Percentage  of  deaths  per  1000  from  consumption  in  cliildren  from  one  to 

fifteen  years  of  age 526 

71.  Deaths  from  other  tubercular  diseases  in  children  under  fifteen  years  in 

New  York  City 527,  528,  529 

72.  Deaths  from  diphtheria  and  croup  in  children  under  fifteen  years    (Old) 

New  York  City 540 

73.  Percentage  of  mortality  from  diphtheria  in  different  cities  in  the  United 

States    ■ 541 

74.  Relation  between  length  of  the  bacillus  and  its  virulence 546 

75.  Two  hundred  and  nine  cases,   showing  percentage  of  cases  in   which   the 

different  bacteria  w^ere  found  by  culture 548 

76.  Antitoxin  rashes 555 


LIST  OF  TABLES.  xxiii 

TABLE  PAGE 

77.  Three  hundred  and  forty-two  cases  immunized  against  diphtheria  and  the 

result , 569 

78.  Mortality  and  recovery  of  diphtheiia  cases  at  the  Willard  Parker  Hospital 

of  New  York  City 578 

79.  Mortality  per  cent,  and  recovery  of  cases  intubated  at  the  Willard  Parker 

Hospital  of  Xew  York  City 579 

80.  Monthly    averages    of    recovery   in    intubated   cases    of    diphtheria    at    the 

^^■ilIard  Parker  Hospital  of  Xew  York  City 580 

81.  Mortality  per  cent,  of  cases  intubated  at  the  Municipal  Hospital,  Philadel- 

phia, 1894-1904 581 

82.  Mortality  of  diphtheria  ca.ses  treated  in  the  Municipal  Hospital,  Philadel- 

phia, 1S90-1904 582 

83.  Mortality  and  recover}'  of  diphtheria  cases  intubated  at   the  Boston  City 

Hospital,  1889-1904   583 

84.  A  study  of  the  condition  of  the  upper  air  passages  before  and  after  intuba- 

tion of  the  larynx.     Hospital  series 598 

85.  A  study  of  the  condition  of  the  upper  air  passages  before  and  after  intuba- 

tion of  the  larynx.     Private  practice  cases 601 

86.  Deaths  from  measles  in  children  imder  fifteen  years  in  (Old)  Xew  York  City  629 

87.  Five  hundred  and  three  cases  of  measles  and  complications 634 

88.  Three  hundred  and  thirty-three  cases  of  measles  showing  ear  complications.  639 

89.  Deaths  from  scarlet  fever   in  children  under   fifteen  years   in    (Old)    Xew 

York  City • 644 

90.  ilortality  of  cases  of  scarlet  fever  treated  in  Riverside  Hospital,  Xew  York 

City 645 

91.  Two    thousand    six    hundred    and    ninetj^    cases    of    variola,    showing    per- 

centage of  mortiility  in  tlie  vaccinated  and  unvaccinated 680 

92.  Types  of  variola 681 

93.  Deaths  from  typlioid  fever  in  children  luider  fifteen  years  in    (Old)   Xew 

York  City 690 

94.  A  study  of  the  various  forms  and  cliaracteristics  of  the  different  malarial 

parasites    713 

05.  Differential  points  between  syphilis  and  tuberculosis 723 

96.  Differentia]  points  between  syphilis  and  scrofulous  lesions 724 

97.  Blood  count  at  birth,  by  various  writers 726 

98.  Variations  in  number  of  white  blood-corpuscles  found  by  various  writers..  727 

99.  Comparative  Ijlood  changes  in  various  diseases 729 

100.  Length  and  growtli  of  body  in  cretinism 763 

101.  The  association  of  chorea  with  rheumatism 788 

102.  Differential  diagnosis  between  spinal  palsy  and  acute  cerebral  palsy 810 

103.  Deaths  from  cerebro-spinjjl  meningitis  in  children  under  fifteen  years,  Xew 

York  City    825 

104.  Various  forms  of  cerebral  paralysis  and  their  anatomical  lesions 835 

10.).  Differential  diagnosis  between  folliculosis  of  the  conjunctiva  and  trachoma.  865 

1 06.  Whitney's  test  for  sugar  in  urine 926 

1 07.  Table  of  doses  944 


PART  I. 

THE  DEVELOPMENT  AND  HYGIENE  OF  THE  INFANT. 
DIAGNOSTIC  SUGGESTIONS. 


CHAPTEE  I. 
IXFAXCY  AND  CHILDHOOD. 

The  Xew-borx  Infant. 

There  are  several  anatomical  and  physiological  changes  which  occur 
when  an  infant  passes  from  a  passive  intrauterine  to  an  active  extrauterine 
existence.  The  lungs  have  had  no  intrauterine  function.  They  become 
active  as  soon  as  the  infant  makes  its  first  inspiration.  The  stomach  and 
howels  become  active  the  moment  the  first  mouthful  of  food  is  swallowed. 
The  blood-vessels  of  the  umbilical  cord,  which  have  nourished  the  child 
j^ind  connected  it  with  the  circulatory  system  of  its  mother,  rapidly  atrophy 
as  soon  as  breathing  is  established.  The  following  are  the  most  important 
changes  that  take  place  during  the  first  month  of  an  infant's  life: — 

1.  The  meconium  is  expelled. 

2.  The  umbilical  cord  separates. 

3.  The  navel  becomes  cicatrized. 

4.  The  epidermis  cracks  and  falls  off. 

5.  The  hair  is  renewed. 

6.  The  umbilical  vessels  are  obliterated,  and  the  foramen  ovale  is  closed. 
Infancy. — The  term  infancy  is  best  applied  to  that  period  from  the 

end  of  the  first  month  until  all  of  the  milk  teeth  have  appeared,  which  is 
about  the  end  of  the  second  year  of  life. 

There  are  certain  anatomical  peculiarities  which  may  be  important  to 
mention,  namely : — 

1.  The  thymus  gland. 

2.  The  large  size  of  the  liver. 

3.  The  existence  of  an  anterior  and  posterior  fontanel. 
Childhood. — The  term  childhood  is  applied  to  that  period  from  the 

end  of  the  second  year  to  about  the  sixteenth  year. 

Childhood  ends  when  puberty  begins.  Then  follows  the  stage  of  adoles- 
cence. 

(1) 


CHAPTER  II. 

THE  DEVELOPMENT  OF  THE  VARIOUS  SENSES. 

Mental  Faculties.^ 

The  following  is  the  order  in  which  the  various  senses  appear  devel- 
oped :  taste,  sight,  touch. 

Keflex  Actions. — Yawning  may  begin  at  the  end  of  the  first  week  ot 
life. 

Sighing  commences  in  the  twenty-eighth  week. 

Urine  is  passed  and  attention  called  to  it  by  the  infant  between  the 
thirty-sixth  and  fortieth  weeks.  From  this  time  on  it  is  advisable  to  try  to 
train  the  child  to  be  clean  and  use  a  chair. 

Suckling  or  Nursing. — This  seems  to  be  congenitally  acquired.  Be- 
tween the  eighth  and  tenth  months  an  infant  should  know  enough  to  prop- 
erly guide  a  nursing  bottle  to  its  mouth.  It  should  also  know  enough  to 
properly  inspect  its  various  toys  at  this  age. 

Supporting  the  Head. — The  infant  should  support  its  head  for  a  few 
moments  in  the  fourteenth  week,  and  should  be  able  to  properly  support 
the  head  about  the  sixteenth  week. 

Sitting  usually  commences  between  the  seventeenth  and  twenty-sixth 
weeks.  The  child  should  be  able  to  properly  support  the  body  between  the 
thirty-sixth  and  fortieth  weeks.  About  the  forty-second  week  the  child 
should  be  strong  enough  to  support  its  back  thoroughly.  Commencing  with 
the  forty-fifth  week  the  sitting  position  should  be  permanently  established. 

When  children  can  sit  up  and  play  they  should  be  placed  on  the  floor, 
having  a  clean  rug  under  them.  Active  movements  can  be  suggested  by 
rolling  a  small  ball  or  giving  the  child  some  toy  to  play  with.  The  tendency 
to  put  everything  into  the  mouth  must  be  considered.  Hence,  large  toys, 
such  as  hollow  rubber  balls,  are  best.  Playing  with  beans,  peas,  and  bullets 
has  frequently  given  many  a  physician  an  opportunity  to  try  his  skill  in 
removing  them  from  such  places  as  the  middle  ear,  the  nostril,  and  most 
frequently  the  stomach. 

Stamping  with  the  feet  in  the  forty-fourth  week. 

The  first  attempts  at  walking  appear  about  the  forty-first  week.  Wallc- 
ing  unaided  is  rare  before  the  end  of  the  first  year.    Two-fifths  of  all  children 


*The  brain,  fontanel,  and  reflexes  of  the  body  are  described  in  detail  in  Part 
IX,  "Diseases  of  the  Brain  and  Nervous  System." 

(2). 


DEVELOPMENT  OF  THE  VARIOUS  SENSES.  3 

learn  to  walk  between  the  fourteenth  and  fifteenth  months.  Thus  children 
must  not  be  expected  to  walk  properly  until  they  are  one  and  a  half  years 
old. 

Children  having  suffered  with  disordered  stomach  and  bowels,  whether 
from  faulty  feeding  or  inherited  disease  (syphilis)  or  other  organic  dis- 
orders, may,  if  urged  to  walk  in  this  weakened  condition,  invite  deformities, 
such  as  bow-legs. 

Children  will  not  jump,  climb,  throw  things,  or  turn  unaided  before 
they  are  between  two  and  three  years  old. 

Infants  do  not  learn  to  imitate  before  the  twenty-eighth  week. 

Laughing  begins  as  early  as  the  eighth,  sometimes  not  before  the 
seventeenth  week.  An  infant  will  laugh  heartily  with  tears  in  its  eyes 
about  the  forty-fourth  week.  The  mouth  will  show  an  expression  the  mo- 
ment the  infant's  attention  is  attracted,  between  the  third  and  seventh  week. 

Kissing  with  the  lips  usually  at  the  fifteenth  month. 

Tears,  when  crying,  can  be  noticed  after  the  tenth  week. 

Memory. — The  memory  of  an  infant  can  be  noticed  sometimes  before 
the  thirtieth  week. 

The  taste  of  milJc,  the  sense  of  feeling,  the  sight  of  the  mother,  the 
presence  of  the  father  or  the  nurse,  are  distinctly  apparent  about  this  same 
time.  An  infant  will  notice  the  absence  of  its  mother  about  the  fourth 
month,  and  also  notice  the  difference  in  the  sound  of  the  voice.  The  memory 
seems  to  be  most  acute  in  the  fourth  year  of  life.  It  is  surprising  to  see 
how  much  children  will  remember,  and  how  acute  their  mental  faculties 
will  be  in  the  fourth  year  of  life. 

Voice  Sounds. — Children  will  study  the  movements  of  the  mouth  of 
adults,  and  will  learn  to  note  the  difference  in  sound.  They  will  remember 
the  meaning  of  words,  especially  when  brought  into  use  in  connection  with 
certain  objects  or  places.  Words  will  be  uttered  in  accordance  with  no  dis- 
tinct rule.  This  is  a  peculiar  individuality  which  is  difficult  to  record. 
One  child  will  speak  ten  words  at  the  age  of  ten  months,  and  be  in  a 
normal  condition.  Another  child  will  speak  but  six  words  at  the  age  of 
sixteen  months  and  yet  be  physically  and  mentally  in  a  normal  condition. 
This  shows  the  marked  difference  in  various  children  in  apparently  good 
health. 

Very  Late  Speaking,  Slow  Development,  Good  Prognosis.* 

The  center  of  speech  may  be  inactive,  and  show  no  signs  of  develop- 
ment until  the  end  of  the  second  year.  If  the  child  is  otherwise  healthy 
no  alarm  need  be  felt  at  this  state  of  affairs.  If,  however,  the  child  is 
backward  in  its  physical  development  as  well  as  its  mental  development, 

*See  axticle  on  "A.lalui  Idiopatliica,"  Part  IX, 


4  BUDDEN  LOSS  OF  SPEECH, 

then  treatment  must  be  sought  to  remedy  this  condition.    If  a  child  has 
rickets,  its  soft  bones  and  flabby  muscles  require  restorative  treatment. 

Sudden  Loss  of  Speech  Due  to  Paralysis. 

If  an  infant  shows  proper  development,  commences  to  speak,  and  for 
no  apparent  reason  stops  speaking,  the  cause  of  the  condition  should  be 
carefully  investigated.  For  example:  A  child  suffering  from  a  severe 
infectious  disease,  like  diphtheria,  may,  during  convalescence,  develop 
paralysis,  which  might  cause  the  sudden  cessation  of  speech.  The  neglect 
of  treatment  at  such  a  time  may  result  in  permanent  injury  to  the  child. 


CHAPTER  III. 

THE  DEVELOPMENT  OF  THE  BODY. 

Growth  and  Height. 

The  average  height  of  the  new-born  male  is  from  19  ^/j  to  20  inches 
(about  50  centimeters).  In  the  female  from  19  ^/4  to  19  V^  inches  (about 
48.5  centimeters).  Holt's  average  is  one  inch  more  in  both  male  and 
female  children  at  birth.    A  child  grows  most  rapidly  during  its  first  year. 

Table  No.  1. 
Increase  during 

First    year 5  to  6  Vi  inches. 

Secosd   year 2  Vi  to  3  Va  inches. 

Third    year 2  V,  to  2  'A  inches. 

Fourth   year about  2  inches. 

Fifth  to  sixteenth  year annual  increase  from  1  V,  to  2  inches. 

Sixteenth  to  seventeenth  year..l  Vz  inches. 
Seventeenth  to  twentieth  year..l  inch  yearly. 

Diseases  of  the  bones,  rickets,  and  scrofula  retard  growth.  A  child 
should  begin  to  walk  at  the  end  of  twelve  months.  If  a  child,  when  com- 
mencing to  walk,  uses  chiefly  its  toes  and  has  a  limping  gait,  more  espe- 
cially if  symptoms  of  pain  be  noticed  in  one  knee,  and  tenderness  be  caused 
by  handling  the  limb,  commencing  hip-joint  disease  may  be  inferred. 

Dentition. 

Dentition  is  regarded  by  most  authors  as  a  physiological  process.  Teeth 
are  developed  at  birth  and  grow  with  the  infant  until  they  pierce  the  gum. 
A  series  of  nervous  disorders  occur  after  the  fourth  month  and  during  the 
eruption  of  the  teeth.  Such  symptoms  are  a  very  warm  mouth,  red  and 
inflamed  gums,  and  an  excessive  secretion  of  saliva.  Eachitic  children  and 
those  having  a  highly  sensitive  nervous  system  will  be  very  restless  at  night. 
They  will  roll  the  head  and  frequently  cry  with  pain.  A  finger  will  usually 
be  found  between  the  gums  and  the  child  will  try  to  bite  everything  within 
its  grasp.  These  symptoms  seem  to  disappear  after  the  eruption  of  the 
tooth,  so  there  seems  to  be  some  relation  between  the  tooth  and  the  symptoms 
described.  Eotch  states  that  in  certain  infants  during  the  completion  of 
the  development  of  a  tooth,  symptoms  connected  with  the  ear  will  manifest 
themselves.  The  symptoms  are  usually  produced  by  a  congestion  of  the 
blood-vessels  of  the  ear  which  is  accompanied  by  pain  and  sometimes  results 
in  an  inflammation. 

(5) 


6 


THE  DEVELOPMENT  OF  THE  BODY. 


Treatment  of  Inflamed  Gums. — When  the  gums  are  tense  and  inflamed, 
severe  nervous  manifestations  frequently  exist.  An  incision  made  into  the 
gums,  deep  enough  to  reach  the  tooth,  has  frequently  been  the  means  of 
producing  relief  by  local  depletion.  Eelieving  the  tense  gum  besides 
abstracting  the  blood  has  served  me  in  some  cases.  The  indiscriminate 
lancing  of  the  gums  must  be  warned  against.  In  most  cases  local  applica- 
tion will  relieve.  The  application  of  a  1  to  5000  solution  of  adrenalin  acts 
very  well.  It  may  be  repeated  every  hour.  A  drop  of  laudanum  on  absorb- 
ent cotton  placed  in  the  middle  ear  seems  to  act  well  in  some  instances. 
In  rare  instances  we  will  be  told  that  a  child  has  had  convulsions.  I  must 
emphatically  reiterate  that  such  cerebral  or  nervous  symptoms  are  apt  to 
occur  in  the  sick  infant,  and  will  never  occur  in  the  healthy  infant. 


Fig.  1. — A,  tympanic  cavity;  B,  otic  ganglion;  C,  tooth;  D,  internal 
carotid;  E,  tympanic  branch;  F,  auriculo-temporal  nerve;  G,  auricular 
branch  of  auriculo-temporal  nerve.  The  dotted  line  connecting  B  and  0 
represents  the  inferior  dental  nerve.     (Rotch.) 


The  association  of  bronchitis  or  diarrhoea  must  be  looked  upon  as 
entirely  independent  of  dentition.  The  laity  are  very  willing  to  ascribe 
most  disorders  arising  at  or  about  the  period  of  dentition  as  due  to  the 
teething.  The  following  case  will  illustrate  how  careful  one  must  be  not 
to  be  guided  by  the  statements  of  irresponsible  persons,  and  diagnose  den- 
tition : — 

A  child,  fifteen  months  old,  was  seen  by  me  in  consultation.  This  was  a  well- 
nourished,  breast-fed  infant,  and  had  four  incisors,  two  upper  and  two  lower.  The 
mother  stated  that  the  child  had  had  a  cough  and  fever  at  and  before  the  appearance 
of  each  tooth.  She  was  very  emphatic  in  stating  that  her  baby  was  "teething." 
There  was  anorexia  and  slight  constipation.  A  dose  of  castor-oil  was  given,  but  the 
symptoms  continued.  The  child  was  very  thirsty  and  seemed  to  lose  flesh.  The 
temperature  in  the  rectum  was  103°  F.,  pulse  150,  respiration  30.  An  examination 
of  the  chest  showed  moist  rales  and  quite  diffuse  rhonchi.  There  was  a  marked  area 
of  dullness  and  bronchial  breathing  in  the  upper  lobe  of  the  right  side.  The  diag- 
nosis of  pneumonia  was  made.    Four  or  five  weeks  later  I  again  saw  this  child.    The 


DENTITION.  7 

cough  still  existed  and  a  suspicion  of  whooping  cough  was  expressed.  An  explora- 
tory puncture  showed  pus.  The  diagnosis  of  empyema  was  made.  The  child  was 
operated  upon  and  made  a  brilliant  recovery. 

The  teeth  usually  appear,  according  to  Professor  Baginsky,  between 
the  third  and  tenth  months.  The  usual  rule  is  for  normal  dentition  to  begin 
about  the  seventh  or  the  eighth  month. 

In  a  great  variety  of  children  premature  teething  is  recorded;  I  have 
seen  a  great  many  children  born  with  two  or  more  teeth. 

Rachitic  children,  as  a  rule,  teeth  very  early  or  very  late.  In  the  large 
children's  service  with  which  I  have  been  connected  I  have  observed  the 
eruption  of  teeth  many  times  as  early  as  two  or  three  months  in  very  rickety, 
bottle-fed  children.  These  teeth  soon  decay,  and  are  then  known  as  carious 
teeth. 

In  syphilitic  (congenital)  children  premature  dentition  is  frequently 
seen. 

The  first  teeth  are  known  as  milk-ieeth. 

The  following  table  will  show  the  usual  rule  followed  by  normal  denti- 
tion in  the  average  child: — 


Table  No.  2. 

19] 

1  11  1 

1  i^n 

1  13  1  5  1  3  1  4  1  6  1 

14  1 

9  1 

1  17 

20  1 

1  15  1  7  1  1  1  2  1  8  1 

16  1 

10  1 

1  18 

The  milk-teeth  are  twenty  in  number;  thus,  one  and  two  are  the  lower 
incisors,  usually  first  teeth;  then  follow  three  and  four,  upper  incisors. 

Normal  children  usually  teeth  in  pairs,  and  not  singly,  whereas  rachitic 
children  usually  have  an  eruption  of  single  teeth,  and  distinct  backward- 
ness in  their  appearance.  Deciduous  teeth,  commonly  called  milk-teeth, 
remain  until  a  child  is  6  years  old,  when  the  permanent  teeth  appear. 

Baginsky  emphasizes  the  fact  that  enough  stress  is  not  laid  on  the 
clinical  importance  of  carious  teeth  as  indicating  tuberculosis  and  scrofulous 
conditions.  In  the  section  on  treatment  of  rickets  I  have  mentioned  the 
value  of  a  nitrogenous  diet,  especially  proteids  (albuminoids),  to  aid  in 
the  formation  of  bony  structures.  The  teeth  are  also  included  in  this 
category. 

Thus,  when  such  drugs  as  glycerophosphate  of  lime  or  iron  and  hygienic 
measures  are  indicated  for  the  treatment  of  rickets  they  are  of  especial 
value  when  backwardness  in  teething  exists. 

When  diarrhoea  or  cholera  infantum  cleanses  the  system  and  when  the 
disease  is  arrested  or  well  under  way,  normal  physiological  conditions,  such 
as  dentition  previously  delayed,  are  vigorously  continued.  Frequently  teeth 
will  appear  immediately  following  such  an  acute  disease,  thus  an  apparent 
delayed  dentition,  due  to  a  pathological  process,  will  be  attributed  by  the 
laity  to  the  disease  or  sickness  called  teething. 


THE  DEVELOPMENT  OF  THE  BODY. 


Fig.  2. — Two  Middle  Lower  In- 
cisors. Three  to  Ten  Months; 
Average,  Seven  Months. 


Fig.  .5. — Four  Upper  Incisors.     Nine 
to  Sixteen  Months. 


Fig.  4. — Two  Lateral  Lower  Incisors  and  Four  Anterior  Molars. 
Thirteen  to  Seventeen  Months. 


Fig.  5. — Four  Canines.     Sixteen  to 
Twenty-one  Months. 


Fig.  C— Twenty  Milk  Teeth.  Twenty- 
three  to  Thirty-six  Months,  although  the 
Average  is  Twenty-four  to  Thirty  Months. 


'1  am  indebted  to  Dr.  Dillon  Brown  for  the  illustrations,  which  have  recently 
appeared  in  "The  Nursery," 


CHAPTER  IV. 


DIAGNOSTIC  SUGGESTIONS.* 


It  is  a  very  difficult  matter  to  give  as  distinct  clinical  pictures  of 
children  in  certain  diseases  as  we  can  of  adults.  The  following  points  are 
important  enough  to  be  noted : — 

First. — There  is  an  absence  of  expectoration  in  respiratory  diseases. 
Infants  cough  and  usually  swallow  their  expectoration. 

Second. — An  absence  of  distinct  chills  and  rigors  as  seen  in  adults. 

Third. — The  tongue,  so  valuable  in  adults  as  an  aid  to  diagnosis,  may 
frequently  be  overlooked  as  a  symptom  of  importance  in  young  children. 

Fourth. — Very  high  temperature  and  pulse-rate  may  be  associated  with 
trivial,  just  as  well  as  they  only  too  frequently  denote  serious  conditions. 
A  normal  temperature  is  frequently  seen  in  septic  diphtheria;  we  must 
therefore  not  judge  a  case  by  the  temperature  alone. 

Fifth. — The  great  peristaltic  activity  and  the  anatomical  difference 
in  the  shape  of  the  stomach  at  birth  render  such  symptoms  as  vomiting  and 
diarrhoea  trivial  compared  with  what  such  symptoms  would  denote  in  an 
older  and  fully  developed  child. 

Dr.  West  ably  says:  "You  cannot  question  your  patient,  or,  if  old 
enough  to  speak,  still,  through  fear,  or  from  comprehending  you  but  im- 
perfectly, he  will  probably  give  you  an  incorrect  reply.  You  try  to  gather 
information  from  the  expression  of  his  countenance,  but  the  child  is  fretful 
and  will  not  bear  to  be  looked  at;  you  endeavor  to  feel  his  pulse,  he  strug- 
gles in  alarm;  you  try  to  auscultate  his  chest,  and  he  breaks  into  a  violent 
fit  of  crying."  Such  technical  difficulties  each  medical  man  must  try  to 
overcome,  and  here  it  is  that  the  ingenuity  of  the  practicing  physician  is 
brought  into  play. 

There  are  a  great  many  important  points  which  have  a  bearing  upon 
the  diagnosis  and  which  it  is  well  to  formulate:  First,  try  to  examine  the 
infant  when  asleep.  Note  the  color  of  the  face,  if  flushed  or  pale;  the 
color  of  the  lips  if  white  or  cyanotic;  the  condition  of  the  skin,  if  dry  or 
moist;  if  perspiration  is  confined  to  the  head  or  forehead,  or  if  it  affects 
the  whole  body.  Second,  note  the  frequency  and  character  of  respiration, 
if  painful  or  natural ;  moaning,  twitching,  or  grinding  of  teeth ;  the  action 


*The  Babinski  reflex,  Kernig's  sign,  Tache  cerebrale  and  the  technique  of  lumbar 
puncture  are  described  in  detail  in  the  chapter  on  "Meningitis."    Part  IX. 

(9) 


10  DIAGNOSTIC  SUGGESTIONS. 

of  the  nostrils,  if  quiet  or  dilating;  the  eyes  if  closed,  partly  closed,  or 
staring.  Third,  note  the  condition  of  the  fontanels,  if  closed  or  open,  if 
pulsating,  if  distended,  full,  and  bulging,  or  if  sunken. 

The  pulse-rate  should  be  noted.  In  counting  the  pulse-rate  certain 
allowances  must  be  made  for  excitement.  The  sudden  slamming  of  a  door, 
etc.,  will  startle  infants  and  cause  the  pulse  to  increase  at  times  from  ten 
to  twenty  beats. 

The  pulse  varies  in  infants  from  110  to  150.  It  may  be  irregular,  con- 
sistently with  health.  After  the  seventh  year  it  is  found  to  be  quicker  in 
the  female.  It  is  sometimes  slower  during  sleep.  A  very  slow  pulse  is  not 
always  an  indication  of  cerebral  disease. 

In  a  study  of  over  1000  children  in  health,  the  following  average  table 
of  pulse  was  found  (Fischer)  : — 

Table  No.  3. 

At  birth 130  to  140 

First  year 115  to  130 

Second  year 100  to  115 

Third  year 90  to  100 

Seventh  year  86  to  96 

Fourteenth  year  84  to  94 

Table  No.  4. 

Pulse  Rate: 

While  Asleep.  Awake,  Crying. 

Infant  ten  days  old 146  164 

One  month  old 150  176 

Two  months  old 120  150 

Three  months  old 112  148 

Six  months  old 93  122 

One  year  old 100  120 

Two  years  old 98  108 

A  diagnosis  can  frequently  be  made  by  the  condition  of  the  pulse-rate 
added  to  the  general  condition.  If  an  infant  is  suddenly  taken  ill  with 
fever,  with  symptoms  of  nausea  and  vomiting,  a  dry  coated  tongue,  and  the 
pulse-rate  about  130,  we  may  look  for  an  acute  gastric  fever.  Such  is  usually 
the  case  if  the  history  points  to  a  diet  of  cake  and  pie,  or  cheese,  in  a  very 
young  child. 

If,  however,  the  child  is  feverish  and  vomits  and  the  pulse-rate  is 
between  70  and  80,  then  we  should  suspect  tubercular  meningitis  rather 
than  an  acute  febrile  disease.  Note  the  condition  of  the  child's  awakening; 
every  young  infant  in  a  healthy  condition  awakens  with  a  smile,  does  not 
frown,  is  not  peevish. 

Frequently,  if  the  clinical  history  is  looked  into,  we  can  learn  Just  when 
the  infant  first  became  restless  or  showed  some  sign  of  disturbance.     This 


TEMPERATURE.  11 

will  usually  mark  the  beginning  of  an  illness,  if  the  same  is  an  acute  con- 
dition. 

The  Respirations. — From  1  to  2  years  of  age  a  child  should  breathe 
from  24  to  36  times  in  a  minute.  The  breathing  should  be  diaphragmatic 
in  character;  in  ordinary  breathing  there  should  be  no  recession  of  the 
chest  walls;  this  occurs  in  sobbing  or  if  a  mechanical  impediment  exists 
to  the  entrance  of  air  into  the  lungs. 

The  number  of  respirations  per  minute  ranges  from  30  to  50;  in 
early  infancy  39  is  the  actual  average. 

Table  No.  5. 

From  two  months  to  two  years,  the  average  is  35. 
From  two  yeare  to  six  years,  the  average  is  18  during  sleep,  23  awake. 
From  six  years  to  twelve  years,  the  average  is  18  during  sleep,  23  awake. 
From  twelve  years  to  fifteen  years,  the  average  is  18  during  sleep,  20  awake. 

Temperature. — The  normal  temperature  of  the  child  taken  in  the 
rectum  varies  between  99  Vb"  to  100°  F.  Fever  undoubtedly  exists  if  tem- 
perature over  100°  F.  is  noted.  The  cause  should  be  searched  for.  No 
indication  is  more  simple  or  more  valuable  than  that  supplied  by  the  ther- 
mometer. By  its  aid  alone  we  are  often  led  to  suspect  the  advent  of  typhoid 
or  scarlet  fever,  or  to  detect  some  latent  pneumonia,  or  tubercle  produc- 
ing irritation,  or  some  other  malady  which  we  had  overlooked.  It  should 
be  remembered  that  rigors  do  not  occur  in  very  young  children,  but  that 
convulsions  and  delirium  correspond  in  a  great  measure  to  rigors  and 
headache  in  an  adult.  The  temperature  is  an  important  guide  as  to  the 
condition  of  an  infant.  The  pulse-rate  and  the  character  of  the  pulse  are 
even  more  important. 

Dr.  Finlayson  has  bestowed  much  attention  on  the  subject  of  tempera- 
ture in  young  children,  and  his  observations  go  to  show: — 

1.  That  there  is  a  fall  of  temperature  normally  in  the  evening  of  1°, 
2°,  or  even  3°  F. 

2.  This  fall  may  take  place  before  sleep  begins. 

3.  It  is  usually  greatest  between  7  and  9  p.m. 
5.  The  minimum  is  at  or  before  2  a.m. 

5.  After  2  a.m.  it  again  rises,  and  that  independently  of  food,  etc., 
being  taken — rises  in  fact  during  sleep. 

6.  The  fluctuations  Ijetween  breakfast  and  tea  are  usually  trifling. 

7.  The  rise  ifa  a  day  to  104°  or  105°  F.  precludes  typhus  and  typhoid, 
not  scarlatina. 

8.  In  typhoid  a  gradual  increase  for  the  first  four  days  with  morning 
remissions  is  diagnostic  (Wunderlich). 

9.  In  tubercle  the  evening  temperature  is  as  high  or,  according  to  Dr. 
Ringer,  higher  than  in  the  morning. 


12  DIAGNOSTIC  SUGGESTIONS. 

EuLES  TO  BE  Observed  in  Taking  Temperature  of  Infants. 

1.  Be  sure  you  have  a  good  thermometer. 

2.  Inspect  it  and  see  that  it  is  well  shaken  down  to  below  normal  before 
using  it. 

3.  Anoint  it  with  vaseline  or  oil. 

4.  Always  use  the  rectum  for  infants. 

5.  Eemember  that  infants  always  object  to  interference,  hence  the 
thermometer  should  he  watched,  otherwise  an  accident  may  happen. 

6.  The  best  position  for  the  child  is  to  lay  it  face  downward  on  the 
nurse's  lap. 

7.  Eemember  that  impacted  fa?ces  in  tlie  rectum  and  fermentative  con- 
ditions usually  increase  the  temperature. 

The  Eye. — Squinting  in  acute  illness  is  a  grave  prognostic;  it  may 
occur  from  reflex  irritation  or  from  paralysis,  or  from  convulsions,  but  the 
convulsions  may  cease  and  the  squint  remain  for  awhile  or  even  perma- 
nently. When  strabismus  occurs  in  tubercular  meningitis,  it  is  usually  a 
fatal  sign. 

A  small  pupil  is  not  so  common  as  a  large  one;  it  occurs  in  active 
congestion,  in  opium  poisoning,  and  in  sleep.  It  should  be  remembered 
that  the  eye  is  always  more  or  less  turned  up  beneath  the  upper  lid.  Large 
pupils,  if  equal  in  size,  are  only  of  grave  import  when  insensible  to  light; 
inequality  of  the  pupils  coming  on  in  acute  illness  is  a  very  grave  prog- 
nostic. M.  Jadelot  has  noticed  that  the  form  of  the  pupil  is  irregular  in 
children  suffering  from  the  intestinal  irritation  of  worms. 

The  following  aphorisms  of  Bouchut  are  of  practical  value: — 

1.  In  early  childhood  thei'e  is  no  relation  between  the  intensity  of  the 
symptoms  and  the  material  lesion.  The  most  intense  fever  with  restless- 
ness, cries,  and  spasmodic  movements,  may  disappear  in  twenty-four  hours 
without  leaving  any  trace. 

2.  Abundant  perspiration  is  not  observed  in  very  young  children;  it 
is  entirely  replaced  by  moisture. 

3.  Fever  always  presents  considerable  remissions  in  the  acute  diseases 
of  young  children. 

4.  In  the  chronic  diseases  of  infancy,  fever  is  almost  always  inter- 
mittent. 

5.  When  children  are  asleep  their  pulse  diminishes  from  15  to  20 
beats.  The  muscular  movements  which  accompany  cough,  crying,  agitation, 
etc.,  raise  the  pulse  15,  30,  or  even  40  pulsations. 

G.  The  diseases  of  youth  always  retard  the  process  of  growth. 

It  is  a  good  plan  to  auscultate  the  chest  before  resorting  to  percussion. 
The  back  of  the  chest  is  the  most  important  to  auscultate  in  a  sick  child. 
If  there  are  no  pliysical  signs  pointing  to  bronchitis  or  pneumonia  in  the 


THE    CRY.  13 

back  of  the  lungs,  then  it  is  unlikely  that  the  front  of  the  chest  will  show 
any  signs.  To  be  sure,  however,  both  back  and  front  of  chest  should  be 
examined. 

Dr.  Vogel  gives  a  valuable  caution,  viz.,  that  dullness  on  the  right  side 
■posteriorly  is  a  normal  physiological  condition.  Owing  to  abdominal 
pressure  the  abdominal  organs,  and  notably  the  liver  (as  especially  affecting 
the  right  side),  is  pressed  upward. 

Gestures  are  often  significant.  In  brain  disease  the  child  puts  its 
hand  to  its  head,  pulls  at  its  hair,  rolls  its  head  on  the  pillow,  and  beats  the 
air.  In  abdominal  disease  the  legs  are  drawn  up,  the  face  is  sunken  and. 
anxious,  and  the  child  picks  at  the  clothes.  In  urgent  dyspnoea  it  tears 
at  its  throat  or  puts  its  hand  in  its  mouth,  especially  when  false  membranes 
are  forming,  or  the  tongue  is  much  furred,  as  in  fever,  etc. 

The  cry  varies;  it  is  labored,  as  if  half  suffocated,  or  as  if  a  door  were 
shut  between  the  child  and  the  hearer,  in  pneumonia  and  capillary  bron- 
chitis ;  it  is  hoarse  in  croup,  brassy  and  metallic,  with  crowing  inspirations ; 
in  cerebral  disease,  especially  in  hydrocephalus,  it  is  sharp,  shrill,*  and  soli- 
tary, the  so-called  "cri  hydrocephalique,"  whereas  in  marasmus  and  tuber- 
cular peritonitis  it  is  moaning  and  wailing.  Obstinate  and  long-continued 
crying  lasting  for  hours  is  referable  usually  to  one  of  two  causes;  earache 
or  hunger.  A  louder,  shriller  cry,  also  on  coughing  or  produced  in  moving 
the  child,  is  pleuritic.  A  cry  accompanied  with  wriggling  and  writhing  and 
preceding  defecation  is  intestinal.  M,  Billard  distinguishes  between  the 
cry  and  the  return,  the  cry  proper  being  the  expiratory  act,  while  the 
return  occurs  during  inspiration.  The  cry  proper  is  sonorous  and  prolonged ; 
the  return  is  shorter  and  sharper;  the  return  is  feeble  in  young  infants, 
but  increases  in  strength  as  the  child  grows  older.  It  is  the  return  that 
grows  weak  or  ceases  toward  the  end  of  all  diseases.  ]\Ioaning  is  especially 
characteristic  of  the  alimentary  canal. 

The  Tongue. — The  following  are  the  chief  indications  derived  from 
observations  of  the  tongue :  1.  A  furred  tongue  with  whitish  fur  scattered 
over  it  indicates  dyspepsia  and  intestinal  irritation.  2.  A.  red,  dry,  hot 
tongue  points  to  inflammation  of  the  mouth,  stomach,  etc.  3.  Aphtha?  often 
result  from  sheer  starvation  and  neglect.  4.  A  pale  flabby  tongue  marked 
at  the  edges  with  the  teeth  shows  great  debility.  5.  White  fur  is  generally 
indicative  of  fever.  6.  Yellow  fur  of  liver  and  stomach  derangement  of 
long  standing.  7.  Brown  fur  of  a  low  typhoid  condition.  Besides  these, 
special  conditions,  as  the  "strawberry  tongue"  of  scarlatina,  the  glazed 
tongue  of  dyspepsia,  etc.,  will  be  noted  under  the  special  diseases  they  char- 
acterize. 

The  Throat. — iVo  matter  ivhat  the  child  suffers  with,  it  is  imperative 
to  examine  the  throat.  Advantage  can  be  taken  of  the  infant  while  crying 
to  observe  the  tongue,  the  teeth,  the  gums,  the  mouth  in  general,  and  the 


14  DIAGNOSTIC    SUGGESTIONS. 

throat  in  particular.  Tlic  neglect  of  an  exaiiiination  of  the  throat  has  fre- 
quently been  the  means  of  disseuiinating  di})htlieria.  Mauy  a  chiUVs  life 
has  been  sacrificed  by  failure  to  make  a  minute  examination  of  the  throat. 

Sleep. — Healthy  infants  normally  sleep  from  eighteen  to  twenty  hours 
out  of  the  twenty-four.  Thus,  if  infants  are  restless  and  do  not  sleep,  such 
insomnia  denotes  illness. 

Presuming  that  we  have  had  an  opportunity  to  examine  the  infant  dur- 
ing sleep,  let  us  then  have  the  child  undressed  and  notice  the  surface  of  the 
skin ;  it  should  be  mottled,  the  flesh  firm,  the  skin  smooth  and  elastic  to  the 
touch,  and  not  flabby ;  there  should  be  no  impediment  to  the  motion  of  either 
the  arms  or  legs,  they,  should  move  freely;  the  joints  should  be  noted  if  they 
are  swollen,  if  large  or  small;  the  epiphyses  of  the  long  bones  should  be  care- 
fully noted,  and  evidences  of  rickets  determined,  as  this  has  an  important 
bearing  on  various  infantile  diseases. 


-A  Very  Convenient  Tongue  Depressor  is  the 
One  Shown  in  the  Illustration. 

I  have  previously  called  attention  to  the  necessity  of  undressing  a  child 
for  its  proper  examination.  Fever  which  cannot  be  explained  may  have  an 
eruption  of  scarlet  fever  on  the  body.  This  can  only  be  detected  l)y  undress- 
ing and  examining  the  infant. 

X-KAY  OR  EOENTGEN  RaTS. 

The  value  of  the  x-ra3's  as  a  diagnostic  aid  is  beyond  question.  It  is 
especially  valuable  in  painful  accidents  to  the  extremities  where  swelling 
and  inflammation  prohibit  manipulation  of  the  parts.  Foreign  bodies  when 
swallowed  are  easily  located  with  the  aid  of  the  fluoroscope.  T  have  fre- 
quently been  a])le  to  trace  coins  and  buttons  that  were  swallowed,  from  the 
stomach  into  the  intestines. 


X-RAY  EXA^nNATlON.  15 

A  case  of  this  kind  was  referred  to  me  by  Dr.  L.  F.  Haas.  Two  days  after 
the  coin  had  been  swallowed,  the  round  outline  could  plainly  be  seen,  located  in  the 
ascending  colon. 

Displacement  of  the  heart  toward  the  right  axilla  by  a  malignant 
growth  involving  the  left  lung  can  be  very  plainly  made  out  with  the  aid 
of  a  fluoroscope.  An  intubation  tube  that  was  pushed  into  the  oesophagus 
by  an  inexperienced  operator,  was  located  by  me  in  the  intestine  by  this 
means.  Experts  with  the  Roentgen  tube  have  frequently  located  cavities  in 
the  lungs  and  also  effusions  in  the  chest.  Carl  Beck,  of  New  York,  recog- 
nized as  an  expert,  vms  the  first  to  demonstrate  gall-stones  with  the  aid  of 
the  x-rays. 

Difficulty  in  Making  an  X-ray  Examination  in  Children. — I  have  fre- 
quently spent  hours  trying  to  get  an  x-ray  picture  of  a  child.  The  noise 
of  the  spark  and  the  darkened  room  seem  to  frighten  very  young  children. 
If  it  is  vital  that  an  x-ray  examination  be  made  or  a  picture  be  taken,  an 
anesthetic  may  be  necessary. 

In  older  children  an  x-ray  examination  will  aid  in  establishing  the 
diagnosis  in  congenital  dislocation  of  the  hip  joint.  (See  illustration  in 
chapter  on  "Congenital  Dislocation  of  the  Hip.") 


CHAPTER  V. 

GENERAL  HYGIENE  OF  THE  INFANT. 

Hygiene  of  the  ]\[outii  and  Teeth. 

Mouth. — Care  should  be  bestowed  on  the  mouth  and  teeth.  The  new- 
born baby  shoukl  receive  an  occasional  washing  of  its  month  with  a  weak 
Solution  of  boric  acid  and  water.  This  sliould  be  done  very  carefully  and 
gently,  or  the  delicate  floor  or  roof  of  the  mouth  will  be  denuded  of  its 
epithelium  and  invite  infection. 

Bednar  directed  attention  to  the  presence  of  aphthae  due  to  trauma- 
tism.    (See  chapter  on  "Bednar's  Aphtha.") 

The  Teeth. — When  teeth  are  present  they  shoukl  be  kept  clean.  It  is 
especially  advisable  to  have  the  teeth  cleaned  with  a  weak  antiseptic  solu- 
tion such  as  listerine  and  water  once  a  day.  Neglect  of  the  teeth  will  result 
in  caries  and  foul  breath.  A  dentist  should  be  consulted  if  there  is  the 
slightest  evidence  of  decay.  The  necessity  for  healthy  teeth  is  very  appa- 
rent in  infancy  and  childhood.  A  practical  method  of  cleaning  the  teeth 
of  children  is  to  use  a  slice  of  lemon  or  lemon  Juice  applied  with  cotton. 

The  Management  of  the  Navel  (Umbilicus). 
The  Umbilical  Cord.^ 

If  the  child  is  in  a  good  condition  and  is  not  blue  (cyanotic),  and  if 
the  pulsations  of  the  umbilical  cord  have  ceased,  then  the  cord  can  be  tied 
about  one  or  two  inches  from  the  child's  body.  If  the  child  is  feeble  we  can 
gain  by  waiting  for  a  few  moments  as  we  admit  oxygenated  blood  through 
the  umbilical  vessels  into  the  child's  body.  The  point  to  be  remembered 
is  "to  tie  the  cord  if  the  pulsations  therein  have  almost  ceased."  This 
usually  takes  from  two  to  five  minutes. 

Some  authors,  e.g..  Professor  Epstein,  advise  making  a  gauze  pouch 
resembling  a  small  tobacco  pouch  to  tie  the  cord.  This  can  be  easily  ster- 
ilized by  baking  in  an  oven  about  thirty  or  forty  minutes.  Care  must  be 
taken  that  the  heat  is  not  too  great  or  the  gauze  will  be  burnt. 

Do  Not  Use  Oil  or  Salves. — When  salves  or  oils  are  used  they  exclude 
the  air  and  prevent  the  drying  of  the  umbilical  cord,  which  is  so  desirable. 
In  order,  therefore,  to  admit  a  current  of  air  through  the  gauze  to  the  cord 
nothing  greasy  should  he  used.  The  best  thing  to  use  is  arrowroot  or  corn- 
starch or  a  talcum  powder  containing  1  per  cent,  of  salicylic  acid. 


Diseases  of  the  umbilicus — haeinonliages,  etc., — are  described  in  Part  II. 
(IG) 


THE  FIRST  BATH.  17 

The  following  two  prescriptions  are  recommended  as  drying  pow- 
ders : — 

IJ   Talcum    100  grains. 

Acid  salicylic 1  giain. 

Mix  and  apply  thoroughly  every  morning. 

B   Talcum    1 00  grains. 

Boric   acid    1  grain. 

Use  as  above  stated. 

If  the  child's  condition  is  normal  and  healthy  action  takes  place,  then 
the  cord  usually  falls  off  in  ahout  five  to  ten  days." 

After-treatment. — The  after-treatment  consists  in  sprinkling  one  of 
the  above-mentioned  drying  powders,  and  covering  the  region  of  the  nm- 
bilions  with  several  dry  layers  of  plain  sterilized  gauze,  over  which  an 
abdominal  binder  should  be  placed. 

An  excellent  powder  is  sold  in  the  shops  under  the  name  of  Velvet 
Skin  Powder.^      It  contains  the  following  ingredients: — 

Boric  acid    1        gram. 

Lycopodium     0.5     grain. 

Orris  root   7.5     grams. 

Boro-tannate  of  aluminium    0.25  gram. 

Talcuiii  q.  s.  ad  100       grams. 

Yernix  Caseosa. 

The  child  at  birth  is  covered  with  vemix  caseosa.  It  is  Nature's 
lubricant  to  protect  the  infant  from  the  change  of  temperature  prior  to 
and  after  birth. 

It  is  advisable  to  lubricate  the  body  with  olive  or  sweet-oil.  This  will 
soften  and  remove  the  vemix  caseosa.  This  can  be  continued  daily  until 
the  cord  has  fallen  off. 

The  First  Bath  of  the  New-born  Baby. 

The  ease  with  which  an  infection  can  take  place  through  the  umbilical- 
vessels  accounts  for  most  authors  advising  agaitist  tlic  first  hath  hciiig  (jiven 
until  llir  vnihi/iciiJ  cold  linx  scjinnili'it  from  tlir  hoih/.  After  tlie  cord  has 
separated  and  there  is  no  evidence  of  inflaiuuuition  or  suppuration  in  the 
region  of  the  umbilicus,  then  the  first  bath  nuiy  be  given.  This  is  usually 
al)out  the  end  of  the  first  week. 


'The   above    powder    is    made    by   Paliftad:>    Manufacturing   Company,    Yonkers, 
N.  Y. 

-  For  disease  of  tlu  unil)ilicus  read  Pprt  IT,  Chapter  on  ''Umbilicus." 

2    , 


18  GENERAL  HYGIENE  OF  THE  INFANT. 

Bathing  the  J3aby. 

The  temperature  of  the  bath  for  a  new-born  baby  should  be  warmer 
than  the  baths  given  as  the  child's  age  progresses.  It  is  advisable  to  bathe 
a  new-born  baby  in  water  having  a  temperature  between  95°  and  100°  F. 
To  determine  the  temperature  of  a  bath  it  is  necessary  to  have  a  bath  ther- 
mometer.   One  having  a  wooden  casing  is  preferable.     (See  Fig.  8.) 

We  should  never  guess  at  the  temperature  of  a  bath.  Sometimes  a  bath 
that  feels  very  hot  to  a  sensitive  skin  may  not  be  as  warm  as  we  imagine, 
hence  the  rule  should  be  ,  "depend  on  the  thermometer."  The  temperature 
of  the  bath  should  be  lowered  or  made  cooler  as  the  infant  grows  older. 

The  temperature  can  be  lowered  five  degrees  from  month  to  month  until 
the  bath  is  given  at  a  temperature  of  75°  F.  This  is  a  tepid  bath  which  can 
be  continued  during  both  winter  and  summer  months  for  the  first  year  of 
life. 

Additional  Cleanliness. — It  is  self-understood  that  every  infant  requires 
additional  sponge  baths  to  keep  its  buttocks  and  genitals  clean,  especially 


Fig.  8. — Bath  Thermometer. 

BO  after  each  bowel  movement.  If  a  child  is  properly  washed  or  sponged 
it  is  not  necessary  to  overdo  the  use  of  soap. 

The  Use  of  Soap. — Excessive  use  of  soap  will  provoke  eczema.  Soap 
acts  as  an  irritant  to  the  skin  if  over-used.  There  are  some  bland  soaps 
which,  if  used  in  moderation,  will  do  good;  thus,  the  ordinary  olive-oil 
soap,  commonly  known  as  castile  soap,  or  the  ordinary  glycerine  soap  found 
in  drug  stores,  is  very  good.  Medicated  soaps  are  of  no  value  for  a  new- 
born baby,  unless  some  special  form  of  soap  is  required  in  a  skin  disease. 

After  the  Bath. — The  child's  body  should  be  thoroughly  dried  and 
powdered,  especially  in  the  folds  of  the  skin  between  the  thighs,  in  the  arm- 
pits, around  the  neck,  the  back,  and  the  abdomen.  We  should  use  powder 
very  liberally,  as  the  dryer  the  skin  is  kept  the  less  chance  will  there  be  for 
the  development  of  an  eczema. 

Sensitive  Skin. — If  an  infant's  skin  shows  a  tendency  to  be  red  and 
chafed  then  it  is  advisable  to  use  no  soap  at  all,  but  an  ordinary  bath  or  an 
oatmeal  bath  made  in  the  following  manner  will  be  found  advantageous: — 

Oatmeal  Bath. — How  to  maJce  the  hath:  Take  between  two  and  three 
pounds  of  good  oatmeal,  and  sew  into  a  bag  made  of  cheesecloth.  Place  the 
bag  with  the  oatmeal  in  the  infant's  bathtub,  containing  one-half  the  quan- 
tity of  water  to  be  used  for  the  bath.    After  the  bag  has  soaked  for  about 


CLOTHINa.  19 

one-half  hour,  add  enough  water  to  bathe  the  child's  body  therein.  The 
duration  of  the  bath  shall  be  about  five  to  ten  minutes.  After  the  bath  dry 
the  body  thoroughly  and  apply  the  following  ointment  wherever  the  skin  is 

tender : — 

IJ  Calaminaris    5  parts. 

Zinc  ointment 50  parts. 

Apply  with  a  piece  of  clean  gauze  over  the  affected  parts.  Do  not  use 
the  fingers  for  applying  the  salve. 

When  to  Stop  Bathing. — It  is  advisable  not  to  bathe  if  an  infant  has 
an  eczema  or  a  very  reddened  skin,  and  it  is  a  good  rule  to  follow  never  to 
bathe  if  an  eruption  of  the  body  is  present,  unless  such  eruption  is  due  to 
an  irritation  applied  to  the  skin.  Turpentine,  mustard,  and  camphorated 
oil  when  rubbed  into  the  skin  will  cause  an  eruption  resembling  scarlet 
fever.  Under  such  conditions  the  bath  may  be  used;  when  fever  appears 
the  bath  may  be  continued,  providing  there  is  no  eruptive  disease  like 
measles  or  scarlet  fever,  and  then  even  the  baths  may  be  given  if  the  attend- 
ing physician  so  desires.  When  children  have  a  cough  or  during  catarrhal 
manifestations,  it  may  be  advisable  in  some  instances  to  discontinue  the 
bath  for  a  day  or  two.  Great  care  should  be  used  while  bathing  a  child 
suffering  with  vulvo-vaginitis  to  avoid  infecting  the  eyes. 

Clothing. 

In  New  York  and  similar  climates  children  should  be  comfortably 
clad.  The  body  should  never  he  overheated.  The  trouble  usually  found 
is  that  children  are  coddled  and  their  bodies  overheated  by  an  excess  of 
flannels.  I  have  frequently  had  occasion  to  treat  eruptions  similar  to  the 
lichen  tropicus  which  was  produced  by  an  excessive  amount  of  clothing  and 
consequent  perspiration. 

The  body  should  be  well  protected  in  winter,  and  very  loose,  light 
clothes  should  be  worn  in  summer.  No  infant  should  be  strapped  tightly, 
but  due  allowance  must  be  made  for  respiration  and  for  the  normal  exercise 
of  the  infant,  namely,  by  permitting  freedom  of  the  limbs.  No  pressure 
should  be  permitted  on  any  portion  of  the  body,  so  that  the  circulation  is 
not  impeded.    Displaced  organs  can  result  from  very  tight-fitting  bands. 

The  Feet. — The  feet  should  always  be  protected.  I  do  not  approve  of 
hardening  infants  by  exposing  their  bare  legs  to  the  peculiarly  changeable 
climate  of  our  Atlantic  coast.  I  have  frequently  found  digestive  disturb- 
ances which  could  be  attributed  to  cold  feet. 

The  usual  shoe  found  in  the  shops  for  the  new-born  infant,  as  well  as 
the  first  walking  shoe,  are  simply  ornaments  and  not  practical  shoes.  It  is 
advisable  to  devote  at  least  enough  care  to  have  the  shoes  made  on  anatomical 


20  GENERAL  HYGIENE  OF  THE  INFANT. 

lines.     The  accompanying  illustration   (Fig.  9)   shows  the  proper  shape 
for  the  first  walking  shoe. 


Fig.  9. — Proper  Shaped  Shoe  for  Infant. 

The  Abdominal  Band. — The  belly-band  is  a  source  of  great  anxiety  to 
the  mother.  Its  support  is  valuable  for  the  umbilicus,  when  the  child  is 
troubled  with  constipation  or  diarrhoea.  It  is  a  valuable  support  for  the 
abdominal  muscles  if  the  child  is  affected  with  whooping-cough.  It  is  not 
necessary  to  wear  the  band  as  an  abdominal  support  more  than  three  months. 
Delicate  infants,  premature  infants,  or  those  suffering  with  gastro-intes- 
tinal  disturbances  may  require  a  supporting  bandage  for  a  much  longer 
time. 

Night  Clothing. — Due  allowance  must  be  made  for  seasonal  changes, 
so  that  light  clothing  should  be  worn  in  summer  and  a  heavier  set  in  winter. 
Restlessness  will  frequently  be  induced  by  having  the  body  too  warm. 

The  Nuesery. 

To  develop  an  infant  we  require  fresh  air  and  sunshine.  We  must 
only  compare  a  flower  deprived  of  sunlight  and  air  to  that  which  is  devel- 
oped under  ordinary  healthy  surroundings.  An  infant  should  be  given 
the  best  room  in  the  house,  with  a  southern  exposure.  The  reverse  is  usually 
found;  infants  are  put  into  the  smallest  room,  as  though  they  were  in  the 
way.  The  nursery  should  be  cheerful  and  sunny,  and  have  a  temperature 
ranging  between  66°  and  72°  F.  At  night,  when  the  child  is  well  covered, 
the  temperature  may  be  lowered  to  60°  F.  without  hurting  the  infant. 

Ventilation. — This  is  one  of  the  most  important  matters  to  be  consid- 
ered during  the  development  of  the  infant.  An  infant  should  invariably 
be  removed  from  the  room  in  which  it  has  slept,  and  the  windows  of  the 
nursery  should  be  opened  both  top  and  bottom.  After  proper  ventilation 
the  windows  are  closed  and  the  infant  may  be  brought  back  again.  The 
nursery  should  be  ventilated  at  least  two  or  three  times  a  day. 

When  to  Take  an  Infant  Out  of  Doors. — An  infant  one  month  old 
should  be  taken  out  into  the  fresh  air  in  summer,  sometimes  sooner.  It  is 
understood  that  the  first  few  times  a  child  is  taken  out  of  doors,  it  should 
be  taken  into  the  sun,  if  possible,  for  one  or  two  hours.  On  rainy  days  or 
when  it  snows  I  invariably  insist  on  giving  the  infant  air  by  throwing 
open  the  windows  and  dressing  the  child  with  coat  and  cap  as  though  it 


THE  NURSEMAID.        NURSERY.  21 

w^ere  to  be  taken  into  the  street.  This  can  be  done  for  half  an  hour  in  the 
morning  and  afternoon. 

The  Nursemaid. — The  selection  of  a  nurse  is  not  an  easy  matter.  That 
it  is  an  important  matter  we  can  see  when  we  consider  cases  of  tuberculosis 
and  syphilis  that  have  been  unquestionably  transmitted  by  the  nurse  to  the 
child.  My  rule  is  to  exclude  a  nurse  who  suffers  with  catarrh  or  throat 
trouble.  They  are  a  constant  menace  to  a  healthy  child.  Specific  rules 
should  be  given  by  the  family  physician  to  each  nurse  regarding  the  feed- 
ing, bathing,  and  general  hygienic  management.  I  invariably  advise  against 
nursemaids  kissing  children  on  the  mouth.  They  should  never  be  per- 
mitted to  sleep  in  the  same  bed.  I  have  known  more  than  one  case  of  uro- 
genital discharge  transmitted  to  a  female  infant  in  this  manner.  I  prefer 
a  nurse  between  20  and  40  years  of  age,  one  that  is  quiet,  mild  mannered, 
and  that  does  not  "know  everything."  Experimental  feeding,  as  is  fre- 
quently tried,  by  that  miserable  creature  known  as  the  "experienced  nurse," 
is  responsible  for  more  rickets  and  weak  children  than  any  other  method  of 
rearing  children.  It  is  the  mother's  duty  to  consult  the  physician  at  least 
once  a  month  or  oftener,  regarding  details  of  feeding,  etc.,  and  it  is  the 
mother  s  place  to  instruct  the  nurse.  A  mother  who  is  dependent  on  a  nurse 
will  find  that  fact  to  be  a  detriment  to  her  child. 

Method  of  Heating. — An  open-grate  fire  or  a  Franklin  radiator  afford 
the  best  means  of  heating.  Our  city  apartments  in  New  York  are  furnished 
with  steam  heat,  and  a  great  many  have  gas  heating.  These  latter  are  the 
worst  forms  of  heating  and  are  responsible  for  more  catarrhal  affections  of 
the  air  passages  than  anything  else.  I  invariably  advise  the  use  of  a  kettle 
with  steaming  water  to  add  moisture  to  a  room  in  which  a  gas  stove  or  steam 
radiator  is  found. 

The  air  should  be  kept  as  fresh  as  possible;  soiled  diapers  or  soiled 
clothing  should  never  be  dried  in  the  nursery.  Smoking  in  the  nursery 
should  not  be  permitted,  and  kitchen  odors  should  not  be  allowed  to  reach  it. 

light  at  Night. — To  insure  proper  repose  there  should  be  no  light  and 
no  noise  in  the  nursery.  With  modern  conveniences,  such  as  electricity,  a 
small,  green,  glass  bulb  can  be  used  when  a  light  is  necessary.  A  wax  night 
candle  will  answer  for  all  purposes  at  night  if  electric  light  cannot  be  used. 

The  Furniture. — The  simpler  the  furniture  the  better.  The  ease  with 
which  infants  and  children  contract  measles,  scarlet  fever,  and  diphtheria 
shows  the  necessity  for  plain  furniture  and  no  useless  overhangings.  If  the 
physician  will  explain  to  the  mother  that  pathogenic  bacteria  will  remain 
for  months  in  carpets  and  rugs  and  tapestries,  she  will  understand  why 
simpler  means  are  required.  It  is  advisable,  if  possible,  to  have  a  hard 
wood  floor  which  may  be  scrubbed  thoroughly.  All  rugs  should  be  aired 
daily,  and  it  is  safer  to  fumigate  the  same  with  formaline  when  occasion 
requires  (see  Fig.  10.) 


22  GENEKAL  HYGIENE  OF  THE  INFANT. 

The  Bed  and  Pillow. — A  cradle  that  can  be  rocked  should  never  be 
used  for  a  child.  Nothing  worse  than  a  feather  bed  can  be  imagined ;  still 
I  see  them  frequently.  The  best  thing  for  an  infant  to  sleep  on  is  a  hair 
mattress,  and  by  all  means  a  hair  pillow. 


Fig.  10. — A  Very  Convenient  Formaline 
Lamp  is  Schering's. 

Proper  Training. 

From  earliest  infancy  it  is  advisable  to  train  the  baby.  It  should  be 
given  the  breast,  and  after  it  is  through  nursing  or  feeding  from  the  bottle 
it  should  be  laid  in  the  crib.  If  this  habit  is  commenced  early,  a  regular 
habit  of  resting  can  be  formed.  If,  on  the  other  hand,  we  permit  the 
infant  to  sleep  next  to  its  mother's  breast,  it  will  get  into  the  habit  of  being 
fondled  to  sleep.  Bad  habits  will  compel  the  mother  to  be  a  slave  to  her 
child,  and  wise  is  she  who  will  accept  the  honest,  well-meant  advice  of  the 
physician  regarding  regularity  in  habits. 

Bowels. — An  infant  three  months  old  can  be  put  on  the  commode.  The 
best  time  for  the  infant's  bowels  to  move  is  after  the  morning  bottle.  In- 
struct the  mother  to  place  the  child  on  the  chair,  and  if  the  bowels  do  not 
move  naturally,  assist  the  same  by  injecting  about  two  ounces  of  water  to 
which  a  few  spoonfuls  of  glycerine  have  been  added.  This  will  aid  in 
directing  the  infant's  attention  to  its  bowels.  If  the  mother  will  do  this 
regularly  every  morning  the  infant  will  gradually  learn  to  know  for  what 
purpose  it  is  placed  on  the  chair. 

Bladder. — What  is  possible  with  the  bowels  can  be  accomplished  with 
the  bladder.  If  the  mother  or  nurse  will  place  the  infant  on  a  vessel  every 
three  or  four  hours,  the  infant  will  gradually  learn  to  hold  its  urine  until 
such  time.  The  infant  should  be  placed  on  the  vessel  immediately  on  awak- 
ening, be  it  night  or  day.  Children  invariably  empty  the  bladder  on 
awakening. 


EXERCISE.  23 

Hygiene  of  the  Nervous  System. — To  develop  an  infant's  brain  the 
nervous  system  requires  quiet  but  cheerful  surroundings.  Useless  excite- 
ment is  harmful.  To  take  an  infant  and  handle  it  like  a  toy  is  wrong.  I 
have  seen  infants  taken  up  from  a  sound  sleep  to  display  the  "talent"  that 
some  one  had  taught  them.  Nothing  is  more  harmful  than  to  have  the 
mother  compel  her  infant  to  display  various  tricks  during  its  feeding.  While 
this  may  be  a  gratification  to  the  friends,  it  certainly  is  detrimental  to  the 
infant's  brain  and  nervous   development. 

Exercise.     Gymnastics. 

The  infant's  clothing  should  be  loose  enough  to  permit  the  infant  to 
use  its  arms  and  legs  freely.  An  infant  gets  exercise  in  its  bath  while 
kicking  its  legs  and  moving  its  arms.  A  cool  sponge  bath  of  the  body  chills 
the  surface  and  causes  the  infant  to  draw  long  breaths;  this  expands  the 
lungs  and  is  the  best  form  of  pulmonary  gymnastics. 

Leaving  children  in  their  cribs  without  proper  exercises  has  been  the 
means  of  producing  what  some  authors  term  "hospitalism."  This  is  simply 
a  wasted  marasmic  or  atrophic  condition  of  infants  due  to  faulty  hygiene. 
A  child  that  is  six  months  old  should  be  placed  on  a  large  rug  and  permitted 
to  roll  or  crawl  at  will.  When  infants  are  seven  and  eight  months  old, 
and  desire  to  stand,  they  should  be  encouraged  to  do  so.  This  grasping  and 
other  muscular  efforts  stimulate  the  circulation,  besides  giving  tone  to  the 
muscles.  Older  children  should  be  permitted  to  exercise,  so  that  there  is  a 
symmetrical  development  of  the  body.  Walking  is  the  best  out-of-door 
exercise.  Older  children  should  ride  a  bicycle,  or  ride  horseback,  or  play 
ball.  Swimming  is  a  healthy  exercise.  Gymnastics,  both  in  and  out  of 
doors,  should  always  be  encouraged.  In  rainy  weather  older  children  should 
have  pulley  weights,  dumb-bells,  or  rowing  machine  for  house  exercise. 
When  children  do  not  develop  properly  and  show  weakness  of  their  mus- 
cles, passive  movements,  aided  by  massage,  will  be  serviceable  until  the 
child  is  strong  enough  to  continue  its  own  exercise.  Healthy  children 
should  be  encouraged  to  have  out-of-door  exercise  regardless  of  the  weather. 
It  is  self-understood  that  during  storms  children  should  be  kept  indoors. 
It  is  necessary  to  regulate  the  amount  of  exercise  to  the  strength  of  the 
child.  If  fatigue  or  over-exhaustion  are  brought  on  by  excessive  exercise 
it  will  be  found  to  be  just  as  productive  of  harm  as  under-exercise. 


PART  II. 

ABNORMALITIES  AND   DISEASES   OF  THE  NEW-BORN. 


CHAPTER  I. 


PREMATURE  INFANTS. 

An  infant  born  before  280  days  of  intrauterine  life  is  called  premature. 
Some  authors  maintain  that  infants  weighing  less  than  4  pounds  should 
be  considered  premature.  If  the  length  of  the  body  is  less  than  19  inches 
then  we  may  suspect  prematurity.  The  internal  organs,  especially  the  lungs, 
not  being  fully  developed,  we  cannot  expect  normal,  functions.  A  premature 
infant  does  not  cry  but  whines.  There  is  muscular  inertia.  The  circulation 
is  very  poor  and  there  is  a  subnormal  temperature  ranging  between  88°  and 
96°  F. 

Children  born  at  six  and  a  half  months  have  grown  up  strong  at  last, 
although  it  is  not  often  they  survive  if  born  before  the  seventh  month.  The 
great  need  of  such  a  baby  is  heat,  and  the  maternity  hospitals  employ  an 
apparatus,  called  a  couveuse,  brooder,  or  incubator,  especially  devised  to 
supply  it. 

For  family  use  a  couveuse  may  be  bought  at  the  instrument  makers,  or 
hired  from  some  of  them.  This  is  perhaps  better,  as  the  apparatus  is  costly. 
With  an  increased  degree  of  attention  we  may  get  along  fairly  well  without 
it.  If  a  premature  baby  is  bathed  at  all  after  birth,  the  temperature  of  the 
water  should  be  105°  F.,  and  the  greatest  care  should  be  taken,  while  drying, 
to  see  that  the  child  is  not  chilled.  It  should  be  made  very  warm  by  swad- 
dling it  in  raw  cotton,  head  and  all,  leaving  only  the  face  exposed,  wrapping 
it  about  with  a  blanket,  and  tying  it  around  with  a  roller  bandage.  Hot- 
water  bottles  should  be  placed  on  each  side  of  it  as  it  lies  thus  wrapped  up 
in  its  bed,  and  fresh  ones  substituted  frequently.  A  very  convenient  method 
is  to  place  the  child  in  a  baby's  bathtub  half-full  of  raw  cotton,  in  which  a 
number  of  hot  bottles  have  been  concealed. 

The  infant's  only  clothing  consists  of  a  diaper  and  a  shirt.  The  room 
should  be  kept  warm,  and  especially  so  when  this  human  bundle  is  un- 
wrapped for  its  bath.  After  bathing  it  should  be  rubbed  with  sweet-oil  and 
rolled  up  again  in  fresh  cotton.  Often  it  is  better  to  omit  all  bathing,  and 
simply  rub  with  the  oil.  These  premature  infants  lose  considerably  more 
in  proportion  to  their  birth  weight  than  babies  at  term.  This  is  due  to 
(24) 


THE   CARE   OF   PRE-MATLRE   INFANTS. 


25 


ImMuuiiiiiiimiiiiiiiii 

yiUHllBIIIBIIVIWUII 


their  immature  digestive  tract;  also  to  the  fact  that  they  are  almost  always 
intensely  jaundiced.  They  gain  very  slowly;  if  at  the  end  of  two  or  three 
weeks  they  have  reached  their  Ijirth-weight,  they  liave  done  unusually  well. 

The  incubator  here 
described  (see  Fig.  11)  is 
the  one  iised  at  the 
Sloane  Maternity  Hos- 
pital. There  is  a  great 
variety  of  these  incuba- 
tors, but  the  one  made 
by  the  Kn^'-Scheerer 
Company  in  Xew  York 
City  will  answer  all  re- 
quirements. Owing  to 
its  expense  the  manufac- 
turers will  lend  an  incu- 
bator for  a  nominal  sum 
per  month. 

The  apparatus  is  con- 
structed of  steel,  with 
glass  doors  and  one  glass 
window  on  the  side  for 
feeding  purposes,  etc. 
The  heat  generated  in  ( 
communicates  itself  t<  < 
the  water-filled  tubes  E 
on  the  inside,  maintain- 
ing a  uniform  tempera- 
ture at  any  desired  point 
by  means  of  a  spiral- 
tliermo  -  regulator  inside 
wliich  is  controlled  by 
micrometer  adjustment 
from  outside.  The  hy- 
grometer records  the  at-  ^^'  ^^' 
mospheric  conditions  of 
the  chamber.  The  air  supplied  to  the  infant  is  filtered  through  an  absor- 
bent-cotton filter  in  box  A;  this  air  can  be  taken  from  the  room  in  which 
the  apparatus  is  placed,  or  directly  from  the  outside  by  means  of  simple 
tubes.  The  revolving  wheel  M  in  cliimney  indicates  the  perfect  circulation 
of  air.  7?  is  the  gas-burner;  //  regulates  tbe  gas;  D  is  tlie  funnel  through 
which  tank  C  is  filled  ;  L  is  a  liygrometer  to  indicate  atmospheric  conditions; 
r  is  a  sliding  window  used  in  feeding  the  infant. 


-Incubator  made  by  the  Kny-Scheerer 
Company,  New  York. 


26  ABNORMALITIES  AND  DISEASES  OF  THE  NEW-BORN. 

In  some  of  the  babies  the  color  is  poor  from  the  beginning,  and  at  any- 
time they  are  liable  to  attacks  of  cyanosis.  For  these  conditions  a  little 
slapping  to  cause  a  good  cry  or  the  administration  of  oxygen  will  dissipate 
the  blueness.  Often  a  few  drops  of  brandy  in  water  given  every  two  or  three 
hours  will  prevent  further  trouble.  One  must  be  very  sure,  however,  that 
nothing  has  been  aspirated  into  the  larynx  (Griffith). 

A  great  danger  in  the  care  of  these  babies  is  their  susceptibility  to 
infections.  The  incubator  itself  is  a  great  germ  carrier  and  should  be 
regularly  disinfected.  The  weakness  of  the  lungs  and  gastro-enteric  tract 
makes  the  infant  especially  vulnerable.  Unless  the  air  is  filtered  dirt  is 
carried  in  continuously;  consequently,  the  streptococcus,  staphylococcus, 
and  pneumococcus  are  always  present,  seeking  an  avenue  of  entrance, 
through  the  skin  in  eczematous  spots  or  in  areas  of  irritation,  at  the  navel, 
through  the  eyes,  nose,  mouth,  larynx,  lungs,  stomach,  and  rectum,  the 
bacteria  can  gain  admission.  To  prevent  infection  the  most  careful  cleans- 
ing is  necessary,  of  both  the  incubator  and  the  baby.  Undoubtedly  most  of 
the  deaths  of  our  cases  could  be  traced  to  this  source. 

A  Danger  of  Incubators. — An  infant  placed  in  an  incubator  was  found 
dead  one  morning,  suffocated  by  vomited  milk  drawn  into  the  lungs.  To 
prevent  this  catastrophe  Wormser  suggests  that  infants  should  not  be  re- 
placed in  the  incubator  until  a  certain  interval  has  elapsed  after  feeding. 
E.  Wormser  {Ceniralllatt  f.  Gyncehologie,  No.  38). 

Finally,  in  the  carrying  out  of  the  above  essentials  in  the  proper  man- 
agement of  the  premature  infant,  we  require  the  most  patient  and  pains- 
taking attention  on  the  part  of  the  nurse,  and  upon  her  conscientiousness 
depends  the  chance  of  its  survival. 

Eesults. 

The  statistics  are  taken  from  2314  births  which  occurred  at  the  Sloane 
Maternity  Hospital. 

Four  hundred  and  ten  of  these  babies  were  premature,  but  of  these  74 
were  stillbirths,  which  include  macerated  foetus  and  stillborn  cases  of  pla- 
centa praevia,  accidental  haemorrhage,  eclampsia,  and  the  like,  leaving  336 
for  treatment. 

Among  these  cases  was  a  set  of  triplets,  and  there  were  18  pairs  of 
twins;  85  were  treated  as  infants  at  term,  and  of  these  4  died — a  mortality 
of  4  V^  per  cent.;  145  were  put  in  cotton,  and  of  these  12  died — a  mor- 
tality of  8  per  cent.  Some  of  this  class  should  have  been  placed  in  the 
incubator,  but  for  lack  of  room  it  was  impossible;  106  were  incubator  babies. 

These  are  divided  into  two  classes: — 

1.  Those  that  died  within  4  days  after  birth. 

2.  Those  that  lived  longer  than  4  days. 

Twenty-nine  of  the  incubator  babies  died  within  4  days.    All  of  these 


THE  CARE  OF  PREMATURE  INFANTS.  27 

were  more  or  less  asphyxiated  at  birth ;  9  were  breech  cases,  and  of  these  5 
were  difficult  extractions;  3  after  an  accouchment  force  in  placenta  prcevia. 
The  rest  were  vertex  presentations,  and  of  these  2  were  forceps  deliveries; 
6  were  under  7  months  of  uterine  gestation;  22  were  between  7  and  8 
months,  and  1,  8  ^/^  months. 

The  etiology  of  the  premature  labor  was  an  endometritis  in  14 ;  syphilis 
in  2;  albuminuria  in  1;  placenta  previa  in  3;  accidental  haemorrhage  in 
1 ;  persistent  vomiting  in  1 ;  twin  in  1 ;  violence  in  1,  and  in  4  the  labor 
was  induced.  The  largest  baby  weighed  5  ^/g  pounds ;  the  smallest  2  Vi, 
pounds.  Only  5  infants  lived  over  24  hours;  24  were  in  such  poor  condi- 
tion at  birth  that  they  survived  only  a  few  hours.  In  16,  autopsies  were 
held,  and  in  all  of  these  there  was  marked  atelectasis;  in  7  there  were 
hcemorrhages  of  some  degree,  either  into  the  brain  or  into  the  serous  mem- 
branes;   in  2  the  foramen  ovale  was  still  patent. 

Seventy-seven  incubator  infants  survived  the  first  4  days;  51  were 
children  of  primiparge,  27  of  whom  were  out  of  wedlock;  3  infants  were 
under  7  months  of  gestation ;  8  were  over  8  months ;  9  were  breech  presen- 
tations; 1  a  transverse  and  the  rest  vertices;  2  were  of  triplets  associated 
with  albuminuria;  18  were  in  twin  deliveries,  associated  with  albuminuria 
or  hydramnios.  The  cause  of  the  premature  labor  was  endometritis  in  27; 
syphilis  in  4;  phthisis  in  2;  albuminuria  in  7;  accidental  hemorrhage  in 
1 ;  placenta  praevia  in  1 ;  in  2  the  labor  was  induced  for  albuminuria  and 
eclampsia;  1  was  a  Csesarean  section;  another  an  ectopic  gestation  by  a 
laparotomy;  12  were  slightly  asphyxiated  at  birth,  9  moderately  so,  and  5 
deeply  asphyxiated;  2,  after  one  and  one-half  hours'  work  of  resuscitation, 
were  put  in  the  incubator  head  downward,  and  their  condition  was  so  poor 
that  they  were  not  expected  to  live,  but  they  left  the  hospital  gaining  in 
weight;  5  weighed  less  than  3  pounds;  38  between  3  and  4  pounds;  33 
between  4  and  5  pounds;  1  over  5  pounds;  the  average  weight  was  3  V* 
pounds.  During  their  incubator  life  28  had  one  or  more  attacks  of  atelec- 
tasis. All  but  10  were  more  or  less  jaundiced.  The  initial  loss  of  the 
infants  was  from  1  to  17  ^/a  ounces ;   the  average  was  7  ounces. 

These  figures  are  not  quite  correct,  as  the  babies  were  weighed  at  dif- 
ferent intervals,  some  on  the  fifth  day,  some  on  the  seventh  day,  and  some 
not  until  the  fourteenth  day. 

The  period  of  loss  was  from  5  to  22  days,  the  average  11  days;  10  lost 
steadily  until  death ;  1  baby  was  in  the  incubator  only  3  days,  while  another 
lived  there  82  days.  The  average  time  was  19  days.  Some  were  removed 
early  to  make  room  for  others  who  needed  the  place  more  urgently. 

Only  3  of  the  77  cases  vomited.     The  stools  were  normal  in  32. 

One  was  discharged  from  the  hospital  as  early  as  the  eleventh  day; 
and  others,  also,  too  soon  at  their  mothers'  demand.  One  was  89  days  old; 
the  average  was  24  days. 


28 


ABNORMALITIES  AND  DISEASES  OF  THE  NEW-BORN. 


In  16,  diluted  breast-milk  was  supplemented  at  times,  with  a  mixture 
of  cows'  milk  and  water,  with  Russian  gelatine  and  lactose.  In  10,  a  1,  6, 
0.33^  modification  was  used.  In  all  the  rest  diluted  breast-milk  was  relied 
upon.  Twenty-seven  never  nursed  at  the  breast;  of  these  12  died.  A  few 
nursed  as  early  as  the  third  or  fourth  day  two  or  three  times  daily;  others 
not  for  three  weeks,  and  1  not  till  the  sixty-eighth  day.  Of  the  77,  13  died  in 
the  hospital — a  mortality  of  16  per  cent.  The  cause  of  death  was  atelectasis 
and  bronchitis  in  7 ;  acute  asphyxia  from  a  curd  in  the  larynx  in  1 ;  syph- 
ilitic pneumonia  in  1;  cerebral  haemorrhage  in  1;  gastro-enteritis  in  3, 
and  a  patent  foramen  ovale  and  ductus  arteriosus  in  1.  The  condition  of 
3  was  poor  at  the  time  of  discharge,  fair  in  24,  and  very  good  in  37;  33 
were  above  their  birth-weights,  and  57  were  gaining  in  weight.  To  letters 
tt^ritten  about  January  1,  1900,  no  answer  was  obtained  from  28.  Thirteen 
were  reported  as  having  died ;  1  of  these  lived  14  months ;  1  lived  4  V^ 
months ;  3  lived  2  months ;  6  lived  6  weeks ;  1  only  a  month.  Five  of  these 
died  at  the  Nursery  and  Child's  Hospital,  and  2  died  at  Bellevue  Hospital. 
They  were  bottle-fed,  and  the  probable  cause  of  death  was  gastro-enteritis. 

Twenty-one  were  found  to  be  alive  and  doing  well.  Some  had  nursed 
and  the  others  were  bottle-fed.  The  oldest  baby  was  22  months,  and  almost 
all  were  good,  healthy  children.  One  baby  at  7  months  weighed  16  pounds. 
It  weighed  4  ^/jg  pounds  at  birth,  and  nursed  from  its  mother  after  leav- 
ing the  hospital.  The  ectopic  and  the  Ceesarean  babies  were  in  beautiful 
condition. 


Table  No.  6. 


Incubators. 

Tarnier. 
Per  Cent. 

Charles. 
Per  Cent. 

Sloane 
Hospital. 
Per  Cent. 

At  the  Sloane  Hospi- 
tal,     Not     Counting 
Those  Which  Died  in 
a  Few  Hours, 
Per  Cent. 

Saved  at  6    months  .... 
Saved  at  6 J  months  .... 
Saved  at  7    months  .... 
Saved  at  7j  months  .... 
Saved  at  8    months  .... 

16 
36 
49 

77 
88 

10 
20 
40 
75 

22 
41 
75 
70 

66 
71 
89 
91 

Method  of  Feeding. 

The  size  of  the  child  precludes  the  taking  of  an  ordinary  nipple ;  hence, 
various  measures  have  been  tried,  the  most  successful  of  which  has  been, 
according  to  the  author's  experience,  feeding  with  Dr.  Breck's  feeder  for 
premature  infants  (see  Fig.  12).  Feed  at  intervals  of  one  hour,  the  quan- 
tity varying  with  the  age  of  the  infant. 


*Fat,  1;    sugar,  6;    proteids,  0.33. 


THE  FEEDING  OF  PREMATURE  INFANTS. 


29 


A  prematurely  born  bab}'  is  certainly  doomed  without  proper  food, 
and  there  are  so  many  other  factors  to  be  considered  during  its  life  in  an 
incubator,  such  as  ventilation,  its  bodily  warmth  and  cleanliness,  that  too 
much  stress  cannot  be  laid  on  the  value  of  its  food.  WHhout  hrcast-mill-, 
therefore,  I  feel  justified  in  saying:  /  have  yet  to  see  flie  premature  infant 
that  icill  snrrire,  and  hence  I  advise  procuring  hreast-mitk,  containing  no 
colostrum-corpuscles,  but  from  a  woman  having  a  child  anywhere  between 
two  weeks  to  several  months  old,  and  dUuiing  this  hreast-tniR-,  as  stated 
above,  with  a  solution  of  milk  sugar  or  cane  sugar. 

Yoorhees^  says:  "Eegarding  the  care  of  premature  babies  in  incu- 
bators, Ave  have  relied  mainly  on  diluted  l)reast-milk,  and  have  only 
employed  diluted  cows'  milk  in  weak  proportions  when  it  was  impossiljle 


Fig.  12. — Dr.  Breck's  Feeder  for  Pre- 
mature Babies.  Can  be  made  witli  a  Fig.  13. —  (a)  Funnel,  {h)  Rubber 
medicine  dropper  to  which  a  nipple  is  Catlieter.  (c)  Glass  Connecting  Tube, 
attached.  {d)    Rubber  Tube  and  Stopcock. 

to  obtain  the  former.  In  our  opinion  our  results  would  have  l)een  much 
poorer  without  the  help  of  mothers'  milk." 

Ill  rare  instances,  when  infants  are  very  weak  and  seem  l(i  doze  and 
will  not  swallow,  they  should  be  fed  witli  a  Xo.  8  American  (Tiemann  & 
Co.)  rubber  catheter  attached  to  a  rul)l)ei'  tube  about  one  foot  in  length 
and  ending  in  a  funnel.     (See  Fig.  13.) 

A'erv  small  fiuantities  of  food  shoidd  l)e  used  in  gavagc-feedings  of  the 


^Archives  of  Pediatrics.  3Iav.  1900. 


30 


ABNORMALITIES  AND  DTSKASES  OK    TlIK  NEW-BORN, 


moiitli  or  whi'R  fee(liii>i-  tlirmiuli  llic  nose.  Xo  iiioTc  than  1  to  (1  (li'aclnii!^ 
t^lioiikl  be  used,  and  thus  we  can  feel  our  way.  Jt  is  a  good  i)oint  to  reuiem- 
her  that  the  pharynx  heing  very  sensitive,  the  irritation  of  tlie  tube  passing 
into  the  stoiuacli  may  ])rovoke  regurgitation  of  some  of  tliis  food,  and  fre- 
(|uently  vomiting  will  he  j)rodueed. 

Baby  ]\I.,  born  ilarch  31,  1909,  was  sent  by  Dr.  I.  L.  Ilill  to  my  service  in 
the  Babies'  Wards  of  the  Sydenham  Hospital.  The  weight  at  birth  was  five  pounds 
two  ounces.  Tlie  feeding  consisted  of  mother's  milk  three  draclims  dihited  with 
barley  water  tliree  drachms.      On  April   2d.   when   three  days  ohl,  the  weight  Mas 


ht-. 


SYDENHAM     HOSPITAL 

..Att WEIGHT  CHART  Dait  „/ Si'ii^ii^^li/J-L..I909. 


%     IB 


7   tc 


/i    IB 


j-   IB 


t^  IB 


:^ 


i 


L  2** 


^*2  5/ 


£1?J 


Ti 


Fig.  14. — Birtli:  |  Placed  in  Tncii))ator ;   j  rvfinovcd  from  In('ul)ator. 

five  pounds.  Tlie  infant  could  not  retain  the  diluted  linma)i  milk,  there  was  con- 
siderable jjrojectile  vomiting.  Condensed  milk  was  then  given.  Condensed  milk 
V-  drachm  to  two  ounces  of  sterile  water.  One-half  ounce  was  given  at  each  feed- 
ing. This  food  was  retained  but  the  infant  emaciated  and  its  lowest  weight  was 
four  ])oimds.  fiavage  was  resorted  to  at  every  ntlier  fce;ling.  Tlie  vomiting  became 
less  and  the  weight  increased,  the  infant  gaining  slowly.  TIio  extremities  wei-e  cold. 
The  infant  was  cj'anosed  and  was  placed  in  an  incubator.  It  tlicn  weighed  four 
pounds  four  ounces.  As  the  weight  remained  stationary  for  one  week,  the  condensed 
milk  feeding  was  discontinued  and  two  drachms  of  the  following  formula  were 
given:  Cows'  milk,  .30.0;  barley  water,  50.0;  peptogenic  milk  powder,  V.t  measure. 
The  infant  gained  rapidly,  vomited  less,  and  slept  longer.  Whenever  possible 
we  procured  woman's  milk  iiiid  substituted  it  f"r  the  cows'  milk  feeding.  The 
infant  remained  in  the  incubator  twenty-seven  days,  and  was  removed  weighing 
six  pounds  seven  ounces. 


THE  FKEinx{;  of  i'ni:-MATrKK  txfants.  31 

The  Stool. — Fioiii  nifcoiiiuiu  at  Ijiitli,  the  stool  gradually  become  a  grass-green, 
jelh'-like  mass;  later  it  was  a  j-ellowish-green,  saponified  stool.  The  first  three 
weeks  the  infant  was  constipated.  This  constipation  later  improved  so  that  the 
stool  was  softer,  pasty  in  consistency,  and  yellowish  or  yellowish-green  in  color.  Tlie 
infant  grew  and  developed  and  was  discharged  in  June,  1909,  weighing  eleven 
]iounds. 

Serum  Injections. — The  subcutaneous  injection  of  sterile  horse  serum  was  com- 
menced with  the  idea  of  promoting  nutrition.  About  15  cubic  centimeters  were 
injected  into  the  loose  cellular  tissue  of  the  abdomen,  and,  when  it  was  found  tliat 
it  was  completely  absorbed,  a  daily  injection  of  15  cubic  centimeters  was  ordered. 
Later  30  cubic  centimeters  were  injected  and  absorbed.  No  febrile  reaction  fol- 
lowed such  injection.  Altliough  many  dozens  of  tliese  injections  were  given,  witli  tlie 
usual  aseptic  jirecautions,  not  once  did  an  abscess  or  other  sign  of  infection  occur. 

The  gradual  daily  increase  in  weight  was  attributed  in  some  measure  to  this 
mode  of  treatment. 

Since  my  last  edition  appeared,  I  have  had  excellent  results  with 
artificial  feeding,  having  saved  five  premature  infants  out  of  six.  The 
feeding  was  identical  with  ease  above  described.  Another  suecessfnl  ])rc- 
mature  case  is  described  in  the  article  on  "Caloric  Feeding." 

A  close  study  of  the  details  required  in  the  successful  rearing  of 
undersized  infants  shows  that  the  following  points  are  helpful: — 

1.  A'omiting,  if  present  after  feeding,  means  longer  interval  between 
meals. 

2.  An  undeveloped  and  weak  infant  taking  but  several  drachms  from 
a  medicine  dropper  will  be  better  fed  by  gavage.  Most  of  my  success  has 
been  due  to  gavage  at  regular  intervals  night  and  day. 

3.  The  temjjerature  of  the  infant  is  usually  subnormal.  Tn  addition 
to  placing  the  infant  in  an  incubator,  I  have  its  body  well  oiled,  especially 
the  feet,  and  the  infant  wrapjx'd  in  cotton.  The  heat  of  the  iiu-u])ator 
l)roduces  dryness  of  the  mouth  and  li})s,  therefore  water  is  given  fi^Mpunitly 
by  spoon  or  medicine  drojiper. 

4.  I'o  aid  nictabolisin  and  to  assist  the  bowels,  an  injeciion  of  a  table- 
spoonful  of  warm  sweet  oil  into  the  rectum  helps  to  move  the  bowels.  The 
weight  should  l)e  taken  daily,  and  it  is  important  to  increase  the  ])ercentage 
composition  of  the  food  until  the  infant  gains  in  weight. 

5.  The  great  danger  of  exposure  prohibits  the  daily  bath.  Ikmu-c  Ihc 
infant  should  be  cleansed  by  inunctions  with  warm  oil. 

77/e  Inriihalor. — The  strict  supi'i  vision  of  an  incubator  demands  two 
i rained  nurses.  'Hie  heat  must  be  regulated.  The  thermometer  on  llie 
inside  of  the  incubator  must  frequently  be  observed  and  the  moisture; 
properly  regulated,  so  that  the  air  in  the  incubator  is  iu)t  too  dry. 

As  a  rule,  an  incubator  infant,  if  otherwise  healthy,  shows  restlessness 
when  its  feeding  time  arrives.  The  infant  is  taken  from  the  incubator,  the 
doors  of  the  incubator  are  closed  to  retain  the  heat,  the  infant  is  rapidly 
fed  bv  gavage  or  the  feeder,  and  returned  to  the  incubator. 


CHAPTER  11. 

PROPHYLAXIS  AND  TREATMENT  OF  THE  EYES  IN  THE  NEW-BORN. 

The  vaiiinal  discharge  of  a  pregnant  woman  contains  ])atliogenie  bac- 
teria. This  l're(|nently  gives  rise  to  an  infections  catarrh  in  the  new-horn. 
It  is  therefore  important  to  treat  the  eye  of  the  new-horn  hahy  with 
extreme  care  to  ])i'event  an  infection  whicli  can  produce  serious  results. 

TrEATMEXT  OE  the  F.YES  IK  THE  Xew-borx. 

Ordinarily  the  eyes  shonld  he  washed  with  a  pledget  of  sterilized  cotton 
dipped  in  plain  sterile  water  or  a  2  per  cent.  l)oric  acid  solution.  The 
mouth  and  nose'should  he  similarly  treated.  All  cotton  used  for  the  hygiene 
of  the  mouth,  nose,  and  eyes  should  be  burned  immediately  after  use. 

Ch-ede  advises  the  use  of  a  1  per  cent,  solution  of  nitrate  of  silver. 
One  drop  (no  more  than  one  drop)  is  alloM-ed  to  drop  from  a  solid  glass 
rod  or  a  medicine  dropper  on  the  center  of  the  cornea.  Its  olgect  is  to 
prevent  the  infant  from  acquiring  ophthalmia  neonatorum. 

The  pro])hylaxis  of  blindness  is  worth  studying.  The  Xew  York 
Association  for  the  Blind  reports  many  cases  "of  needlessly  blind  victims 
of  ophthalmia  neonatonnu."'  The  oflficial  census  of  the  blind  for  the 
State  of  iSTew  York  for  I!)0(;  gives  a  total  of  0200,  out  of  which  number 
lO.Si  were  ])reven tabic  blindness,  most  of  them  caused  Ijy  ophthalmia 
neonatorum. 

Garrigues^  states  that  m  Iving-in  asylums  before  this  treatment  was 
adopted,  purulent  o])hthalmia  was  very  prevalent. 

Statistics  show  that  one-half  to  two-thirds  of  those  affected  with 
blindness  lost  their  sight  from  this  cause. 

"When  the  fi'e(|ucucy  of  the  gonococcus  in  the  vaginal  secretions  of 
women  delivered  in  lying-in  asylums  is  considered,  then  the  wisdom  of 
prophylaxis  cannot  be  questioiu'd. 

Of  late  protargol  (10  per  cent,  solution)  has  been  substituted  for  the 
nitrate  of  silver  solution.     It  is  just  as  effective  and  less  irritating. 

Solution  argyrol  (20  ]wv  cent.)  is  very  useful  in  Ihe  catarrhal  affec- 
tions of  infants  and  children.  I  have  seen  very  good  results  during  my 
service  at  tlie  Willard  Parker  Hospital  with  the  same." 


'Henry  J.  Garrigiies:     "Textbook  of  Obstetrics,"  1902. 
-  See  also  Part  X,  "Diseases  of  tbe  Eye." 

(32) 


CHAPTEE  III. 
DISEASES  A^■D  MALFORMATIONS  OF  THE  UMBILICUS. 

Graxuloma. 

A  :mass  of  fungus  or  exuberant  granulations  is  frequently  found  in 
the  mnbilicus.  Sometimes  the  granuloma  resembles  a  large  red  bead.  It 
is  usually  seen  after  the  cord  has  separated.  A  discharge  usually  oozes. 
These  granulations  bleed  very  easily. 

Treatment. — The  application  of  a  solid  stick  of  nitrate  of  silver  to 
thoroughly  destroy  the  granulations  is  usually  all  that  is  required.  If  these 
granulations  persist  then  the  same  can  be  removed  with  the  aid  of  a  sharp 
curette  by  simple  scraping,  after  which  a  dusting  powder  like  europhen 
should  be  used. 

Diphtheritic   Omphalitis. 

The  new-bom  baby  is  occasionally  infected  with  diphtheria.  If  there 
is  an  omphalitis  the  Klebs-Loeffler  infection  can  easily  be  transmitted.  The 
following  case  was  seen  by  me  in  consultation : — 

A  child  4  years  old  suffered  with  diphtheria  of  the  upper  air  passages,  which 
finally  spread  to  the  larynx,  necessitating  intubation.  This  family  lived  in  a 
crowded  apartment.  The  mother  gave  birth  to  an  infant  five  days  later,  and  was 
herself  infected  with  diphtheria  of  the  vagina  and  vulva.  Her  new-born  baby 
was  about  six  days  old  when  I  first  saw  it.  The  umbilical  cord  had  just  sloughed 
away.  The  region  of  the  umbilicus  was  highly  inflamed  and  covered  with  thick 
pseudo-membranes.  The  child  died  on  the  eleventh  day,  of  septica;mia.  A  culture 
taken  showed  Klebs-Loeffler  bacilli.  The  physician  that  attended  this  family  told 
me  that  the  nurse  in  clwrge  of  the  older  child  trith  laryngeal  diphtJwria  also  nursed 
the  mother  and  the  new-born  baby.  He  believed  that  the  infection  was  undoubtedly 
carried  by  tlie  nurse. 

Treatment. — Locally  bichloride  of  mercury,  1  to  2000,  applied  con- 
stantly. Internally,  antitoxin.  (fSee  chapter  on  "Diphtheria.")  A  case 
of  this  kind  requires  the  same  vigorous  treatment  as  any  other  case  of 
diphtheria. 

The  Dangers  Incident  to  Carelessness  in  Handling  the  Xavel. 

If  through  some  accident  the  ligatures  around  the  umbilical  cord 
should  slip,  and  blood  oozes  from  the  wound,  fatal  hemorrhage  can  result. 
'J'he  attention  of  the  physician  should  at  once  be  directed  to  this  condition. 
I'his  can  become  a  very  serious  matter  if  neglected,  hence  it  is  of  the  utmost 
iiiil)ortance  to  remedy  it  at  once.     The  neglect  of  such  things,  besides  the 

(33) 


34 


DISEASES  AND  MALFORMATIONS  OF  THE  UMBILICUS. 


improper  bandaging  or  unclcanlincss  in  this  region,  is  liable  to  cause  not 
onlv  convulsions,  but  blood  poisoning  and  death. 


Fig.  1.5. — Case  of  Omphalocele  admitted  to  the  Babies'  Wards  of  the 
Sydenham  Hospital.  A  semi-globular  tumor  4  inches  in  diameter,  and 
2V2  inches  above  level  of  the  body.  The  stump  of  the  umbilical  cord  is 
seen  on  the  left  side  of  the  tumor.  Sterile  gauze  dressings  were  applied. 
After  several  weeks  the  mass  gradually  slouglied  off  and  the  wound  closed. 
(Original.) 


I'lg.    l(i. — Ajipcaraucc   of    abdomen    four    weeks   after    treatment, 
was  discharged  cured  when  six  weeks  old.      (Original.) 


Case 


Septic  Omptialitis. 

An  infant  was  seen  by  me,  through  tlie  courtesy  of  Dr.  S.  Straus,  in 
this  city  during  the  summer  of  1902.    History,  as  follows: — 

It  was  the  first  child  born;  no  previous  miscarriage;  family  history  excellent; 
no  history  of  .syphilis;  labor  was  easy,  and  baby  was  born  in  natural  manner. 
The  mother  was  in  excellent  health;  had  milk  in  both  breasts;  normal  temperature. 
Asepsis  was  thoroughly  carried  out.  The  infant  had  a  temperature  of  10.3°  F.,  in  the 
rectum,  slight  gastroenteric  complication,  greenish,  colicky  stools;  the  umbilicus 
was  inflamed  and  excoriated;  slight  evidence  of  pus. 

Diagnosis. — Septic  omphalitis  due,  probably,  to  infection  by  the  nurse  with  un- 
clean hands  while  dressing  the  umbilicus. 

Treatment. — Strict  asepsis  to  be  followed.     The  umbilicus  to  be  washed  with 


CONGEXITAL  OBLITERATIOX  OF  THE  BILE  DUCTS. 


6b 


1  to  2000  bichloride  of  mercury.  Sterile  gauze  and  aristol  or  some  drying  powder 
applied.  The  stomach  and  bowels  were  cleansed  with  calomel,  and  the  infant  fed 
every  tAvo  hours  at  its  mother's  breast.  The  child  made  an  excellent  recovery  in 
about  four  or  five  days. 

Meckel's  DivERTicuLUii. 
A  condition  which  may  at  first  simulate  lunbilical  polypus,  and  for 
which  nmliilical  polypus  may  be  a  symptom,  is  the  persistence  of  a  Meckel 
diverticulum.  This  consists  of  the  persistence  of  a  piece  of  intestine, 
usually  patent,  connecting  the  small  intestine  with  the  umbilicus.  It  rep- 
resents a  vitelline  duct  that  failed  to  atrophy  when  the  placental  circidation 
became  established,  and  Ijetrays  its  presence  by  an  escape  of  fteces  fro;ii  the 
umbilicus.     It  is  a  rare  malformation  (Tiotch). 

1.  2.  3. 


Fig.   17. — Illustrating  Effects  of  the  Persistence  of  the  Omphalomesenteric 

Duct    and    Formation    of    the    So-called    Diverticulum    Tumor     (Riesman). 

1.  The  omphalomesenteric  duct  shown  as  an  opening  leading:  from  the  umbilicus  to  the 
ilium.  2.  Showing-  a  small  portion  of  the  proximal  intestinal  wall.  This  may  happen  in  a 
constipated  child,  while  straining-  at  stool.  Tne  same  condition  may  occur  during  a  par- 
oxysm of  whooping-cough.  3,  The  tumor  is  much  larger,  frequently  sausage-shaped.  It 
is  irreducible. 

CoXCxPTNITAL    ObLITERATIOX    OF    THE    BiLE-DUCTS. 

This  condition  has  I:)een  carefully  studied  by  John  Thomson,  of  Edin- 
burgh. He  has  talnilated  his  studies  in  his  book  on  "Congenital  Oblitera- 
tion of  the  Bile-ducts,"  1892. 

Etiology. — There  can  be  no  doubt  that  various  malformations  of  the 
liver  and  bile-ducts  do  occur  which  are  certainly  of  this  nature.  For 
examjDle,  congenital  aljsence  of  the  gall-bladder  has  been  frequently  de- 
scribed, and  some  of  the  cases  were  due  to  arrest  of  development,  although 
many  were  probably  of  inflammatory  origin.  Wenzel  Gruber  has  published 
a  case  in  which  a  forked  cystic  duct  was  found,  and  Konitzky  has  describetl 
another  in  which  the  common  duct  had  an  unusuall«y  long  and  curved 
course,  and  opened  into  the  middle  of  the  horizontal  portion  of  the  duo- 
denum, its  lumen  being  narrowed.  0.  Witzel  also  has  published  notes  of 
an  infant  boiTi  with  a  large  number  of  congenital  al)normalities,  in  whom, 
in  addition  to  hemicephalus,  situs  viscerum  inversus,  six  fingers  on  each 
hand,  etc.,  there  was  a  cystic  condition  of  the  liver  and  complete  imper- 
meability of  both  the  cystic  and  common  ducts.  Other  developmental 
defects  have  been  observed,  namely,  in  Heschl's  absence  of  the  bile-ducts  in 


36  DISEASES  AND  MALFORMATIONS  OF  THE  UlNIBILICUS. 

the  liver-tissue,  and  in  Professor  Simpson's  want  of  the  spigelian  and  cjuad- 
rate  lobes. 

The  frequency  with  v;hich  this  exceedingly  rare  condition  affects  sev- 
eral members  of  the  same  family  is  very  strongly  in  favor  of  this  view,  and, 
indeed,  it  seems  difficult  to  explain  it  otherwise.  It  has  been  suggested  that 
this  reappearance  of  the  disease  in  the  same  family  might  be  explained  Ijy 
supposing  a  common  syphilitic  taint.  Tliis  suggestion,  however,  cannot  be 
accepted,  for  we  never  find  a  tendency  for  an  extremely  rare  manifestation 
of  syphilis  to  recur  four  or  five  times  in  a  family  without  any  of  the  com- 
mon symptoms  of  that  disease  being  present  at  the  same  time. 

Fathalogy. — The  liver  is  usually  found  much  enlarged,  of  a  very  tough 
consistency — due  to  biliary  cirrhosis — and  of  a  dark  green  color,  owing  to 
the  presence  of  numerous  masses  of  inspissated  bile  in  the  small  bik'-ducts. 
In  the  great  inajority  of  cases  there  is  complete  obliteration  of  some  part 
or  parts  of  the  hepatic,  common  or  cystic  ducts,  or  of  the  gall-bladder, 
while  with  very  few  exceptions,  implication  of  the  blood-vessels  or  other 
tubes  in  the  neighliorbood  is  conspicuous  by  its  absence. 

Pathology  of  the  Lesion  of  the  Ducts. — The  lesion  has  been  ascribed 
to  three  different  morbid  processes,  either  acting  separately  or  in  combina- 
tion, namely : — 

1.  Fentonilis  and  its  results,  acting  on  the  duets  from  outside,  and 
either  compressing  them  or  being  a  source  of  inflammatory  action,  which 
spreads  afterward  to  their  walls. 

2.  An  inflammatory  or  oilier  lesion  of  the  ducts  tlicmselves. 

3.  An  arrest  or  defect  of  development. 

And  further,  various  predisjoosing  causes  have  been  described  as 
accounting  for  these  morbid  processes,  namely : — 

1.  Congenital  sypliilis. 

2.  Dige&tive  disturbance  on  the  part  of  the  parents. 

3.  Injuries  or  exposure  to  cold,  either  of  the  mother  or  child. 

4.  Erysipelas  of  the  child. 

Symptoms. — Such  children  are  jaundiced  at  birth  or  they  become  so 
within  the  first  week  or  two  of  life;  otherwise  they  are  healthy  and  well- 
nourished.  In  some  cases  there  is  meconium  followed  by  colorless  motions; 
in  others  the  faeces  are  devoid  of  color  from  the  very  first.  The  urine  is 
deejdy  l)ile-stained.  The  jaundice  is  of  a  dark  greenish  tinge,  and  lasts  till 
death,  and  the  motions  remain  colorless.  A  certain  proportion  of  the 
chiklren  die  from  mnbilical  haemorrhage  within  the  first  fortnight,  and;  of 
those  who  survive  this  period,  a  large  number  suffer  from  spontaneous  hasm- 
orrhage  from  other  situations.  The  liver  steadily  enlarges,  and  the  spleen 
also.  After  living  some  months  the  children  become  more  or  less  emaciated. 
Spasms  often  supervene,  and  death  ensues  in  the  end  in  a  state  of  exhaustion, 
from  some  trifling  intercurrent  disease. 


CHAPTER  IV. 
HEMORRHAGIC  DISEASES  OF  THE  NEW-BORN. 

Spontaneous  Hemorrhage. 

The  occurrence  of  spontaneous  haemorrhages  is  one  of  the  most  char- 
acteristic clinical  features  in  these  cases.  In  the  cases  collected  by  Thomson, 
in  21  out  of  the  50 — that  is,  in  almost  half  of  the  cases  which  lived  more 
than  a  few  days — the  fact  of  haemorrhages  having  occurred  from  some  part 
of  the  body  is  noted;  and  in  all  probability  it  may  have  occurred  in  some 
of  the  others  also,  although  not  mentioned,  as  the  records  of  many  of  them 
are  so  meager. 

The  situations  of  the  haemorrhages  mentioned  in  Thomson's  collection 
are  as  follows : — 

Table  No.  7. 

Subcutaneous     in  7  of  the  cases. 

Subconjunctival  in  1  of  the  cases. 

Umbilical     in  6  of  the  cases. 

From  nose    in  2  of  the  cases. 

Vomited in  4  of  the  cases. 

From  bowel    in  8  of  the  cases. 

From  mouth in  1  of  the  cases. 

From  lung in  1  of  the  cases. 

Into  gall-bladder  in  1  of  the  cases. 

From   leech-bite    (excessive)  in  1  of  the  cases. 

A  tendency  to  bleed  is  found  in  many  children.  In  the  preceding 
chapter  I  have  described  haemorrhage  as  a  symptom  of  congenital  oblitera- 
tion of  the  bile-ducts.^  I  have  also  described  a  very  serious  haemorrhage  in 
a  case  of  congenital  syphilis  (see  chapter  on  "Syphilis")  which  ended  fatally. 
Direct  infection  through  the  umbilical  vessels  is  a  frequent  cause  of  pyaemia, 
and  this  same  can  result  in  haemorrhage. 

Etiology. — Eitter^  studied  190  cases.  Of  these  24  were  associated  with 
sepsis.  Kilham  and  Mercelis^  describe  haemorrhages  in  10  cases  out  of  54. 
It  seemed  that  these  were  all  due  to  one  and  the  same  pyogenic  infection. 

Gaertner*  describes  a  short  bacillus  which  he  isolated  from  two  cases 
resembling  the  colon  bacillus.  When  the  same  was  injected  into  the  perito- 
neum of  animals,  a  disease  was  produced   accompanied  by  haemorrhage 


*Read  article  on  "Ilismorrhages  in  Congenital  Obliteration  of  the  Bile-duct," 
page  35. 

'Oest.  Jahrbuch  fur  Pediatrik,  1871,  p.  127. 
•  Archives  of   Pediatrics,   March,    1899. 
*Archiv  fur  Kinderheilkunde,  1895. 

(37) 


38  HiEMORRHAGIC  DISEASES  OF  THE  NEW-BORN. 

similar  to  that  seen  in  the  new-born.  Holt  describes  a  case  in  which 
cultures  were  taken  by  Dr.  J.  J.  Mapes  from  which  a  bacillus  resembling 
that  described  by  Gaertner  was  isolated. 

Pathology. — Small  or  large  extravasations  of  blood  may  be  found  upon 
the  various  internal  organs  affected.  The  brain,  the  thymus  gland,  the 
stomach,  the  bowels,  the  pericardium,  the  pleura,  or  peritoneum  may  have 
ecchymoses  upon  their  surface.  A  frequent  source  of  hsemorrhage  is  the 
presence  of  ulcers.    Gastric  and  intestinal  ulcers  are  by  no  means  rare. 

Symptoms. — The  first  symptom  noticed  is  the  presence  of  blood.  This 
may  be  present  in  the  vomit,  in  the  stool,  or  in  the  urine.  There  may  be 
an  oozing  beneath  the  skin  or  from  the  umbilicus.  The  bleeding  does  not 
amount  to  a  very  large  quantity.  The  infant  is  usually  very  anajmic.  The 
pulse  is  small  and  feeble.  The  body  is  emaciated.  The  temperature  fluc- 
tuates ;  as  a  rule  it  is  subnormal,  although  it  may  be  very  high.  The  course 
of  the  disease  is  short,  the  bleeding  usually  ceases  in  a  few  days. 

Umbilical  Hemorrhage. 

Improper  tying  of  the  ligature  around  the  umbilical  cord  or  trau- 
matism frequently  causes  a  slight  oozing.  These  oozings  are  very  easily 
controlled  by  the  application  of  a  proper  fitting  ligature.  When,  however, 
a  spontaneous  hemorrhage  occurs  it  may  be  impossible  to  arrest  the  same 
with  ordinary  means.  In  these  cases  the  haemorrhage  occurs  without  pre- 
vious warning.  As  a  rule  the  umbilicus  has  been  perfectly  normal  for  a 
few  days  prior  to  this  haemorrhage.  Some  authors  state  that  it  may  be 
fatal  in  less  than  twenty-four  hours. 

Gastro-intestinal  Hemorrhage  (Helena), 

Dark-colored,  tarry  stools  are  the  usual  symptom  of  melaena.  The 
black  stool  may  also  contain  clots  of  blood.  A  crucial  test  for  the  presence 
of  blood  in  examining  the  faeces  for  the  presence  of  blood  corpuscles  is  the 
microscope.  Normally  meconium  does  not  contain  blood.  Another  symp- 
tom is  the  vomiting  of  dark-brown  liquids;  occasionally  bright  red  blood 
may  be  present. 

Haemorrhages  of  the  mouth  and  nose  are  generally  due  to  syphilis, 
although  ulcerative  conditions  may  cause  local  haemorrhage.  When  pem- 
phigus or  furunculosis  is  present,  haemorrhages  frequently  occur.  Haemor- 
rhage from  the  female  genital  organs  may  occur  as  well  as  from  any  other 
part  of  the  body.  They  are  usually  associated  with  catarrhal  inflammation 
of  those  parts. 

Diagnosis. — This  is  usually  very  easy,  especially  if  the  bleeding  is 
superficial.  The  diagnosis  is  difficult  when  an  obscure  place  like  the  intes- 
tine is  the  source  of  the  haemorrhage.    The  microscope  will  usually  aid  in 


GASTROINTESTINAL  H.EMORRBiAGE.  39 

establishing  a  diagnosis  of  blood  in  the  excreta.     When  the  bleeding  is 
confined  to  the  mouth  and  nose,  syphilis  should  be  suspected. 

Prognosis. — A  careful  prognosis  should  always  be  given,  although  the 
disease  is  not  necessarily  fatal.  Townsend  studied  T09  cases  and  recorded 
a  mortality  of  79  per  cent. 

A  male  infant,  six  days  old,  was  seen  by  me  through  the  courtesy  of  Dr.  A. 
Goldwater.  The  child  had  vomited  several  times.  The  vomit  contained  blood  of  a 
bright  scarlet  color.  The  stool  had  been  yellowish,  but  now  is  black  and  tarry. 
There  was  a  sliglit  oozing  of  blood  from  the  umbilicus.  When  I  applied  some 
absorbent  cotton  to  the  umbilical  stump,  bright  scarlet  blood  was  seen.  The 
infant  was  well  nourished  and  was  nursed  by  its  mother.  The  diagnosis  of  meliena 
■neonatorum  was  made  by  the  attending  physician  and  I  agreed  in  the  diagnosis. 
The  treatment  consisted  in  the  application  of  the  solid  stick  of  nitrate  of  silver 
to  the  umbilicus,  and  strict  aseptic  dressing.  The  haemorrhages  were  probably  due 
to  p3'ogenic  invasion. 

Treatment. — Umbilical  haemorrhage  can  best  be  controlled,  as  above 
cited,  by  the  application  of  a  solid  stick  of  nitrate  of  silver  followed  l)y  a 
dusting  powder  such  as : — • 

R   Euvophen, 

Alum  usta aa  3ij,  or  8.0 

Sig. :      Dust  over  umbilicus. 

For  the  control  of  intestinal  haemorrhage  astringent  injections  are 
not  to  be  relied  upon.  The  suprarenal  extract  is  a  very  good  haemostatic. 
I  have  frequently  used  very  small  doses  of  hydrastine  hydrochlorate,  ^/^^ 
to  Vioo  grain,  three  times  a  day,  or  V^  to  y,  grain  suprarenal  extract, 
repeated  every  hour. 

The  injection  of  15  cubic  centimeters  to  30  culnc  centimeters  of 
sterile  horse  serum  is  an  excellent  haemostatic.  In  the  case  of  a  "bleeder'' 
recently  seen  by  me  in  the  Babies'  Wards  of  the  Sydenham  Hospital,  one 
injection  of  horse  serum  controlled  the  haemorrhage,  due  to  a  paracentesis 
after  all  local  means  failed. 


CHAPTER  V. 

INJURIES  IN  THE  NEW-BORN. 

Fractures. 

Traumatism  during  labor  is  the  cause  of  most  fractures  in  the  new- 
born baby.  A  predisposition  may  exist,  due  to  defective  ossification.  When 
the  skeleton  is  not  properly  developed,  then  a  separation  of  the  epiphyses  of 
the  long  bones  rather  than  an  actual  solution  of  continuity  of  the  diapheses 
occurs  (Ballantyne). 

This  author  also  doubts  the  osteomalacic  nature  of  fractures.  Ante- 
natal fragility  seems  to  exist  by  direct  heredity.  Griffith  reports  seventeen 
fractures  occurring  in  one  case^  during  the  first  two  years  of  an  infant's 
life.  Thus  we  can  see  that  there  must  be  some  other  factor  at  work  per- 
mitting recurring  fractures,  rather  than  invariably  traumatism. 

It  is  true  that  syphilis  has  frequently  been  given  as  a  possible  cause 
for  a  weak-boned  skeleton. 

Brittle  bones  have  been  attributed  to  rickets.  Prenatal  disease  on  the 
part  of  the  infant  or  its  mother  is  frequently  the  cause  of  fracture.  Linck* 
describes  a  case  of  an  infant  that  was  born  in  little  more  than  one  pain. 
In  this  case  there  was  found  over  thirty  fractures  in  the  limbs  and  ribs. 

Most  of  the  fractures  seen  are  of  the  ^'green-sticlr'  variety.  The  prog- 
nosis in  these  cases  is  usually  good,  unless  some  complication  appears. 

The  following  case  was  seen  by  me  in  consultation  with  Dr.  A.  S. 
Bienenstock,  of  New  York: — 

An  infant  two  days  old  had  a  fracture  of  the  humerus.  The  seat  of  the 
fracture  was  in  the  center  of  the  bone,  and  not  near  the  epiphysis. 

Mother's  History. — The  mother  of  the  infant  suffered  with  diabetes  for  the 
previous  eight  years,  having  between  4  and  4.5  per  cent,  of  sugar.  During  the 
latter  months  of  pregnancy  she  was  in  a  subnormal  condition.  The  labor  was 
dry,  and  quite  some  skill  was  required  to  deliver  the  infant.  Tlie  mother  had  no 
breast-milk,  so  artificial  feeding  was  resorted  to. 

As  this  was  in  midsiunmer  the  infant  soon  became  dyspeptic  and  later 
developed  enterocolitis.  At  the  seat  of  the  fracture  callus  could  be  felt  several 
days  after  I  first  saw  this  infant.    Death  resulted  from  summer  complaint. 

Obstetrical  Paralysis   (Erb's  Paralysis  or  Birth  Palsy). 

This  condition  may  be  seen  soon  after  birth,  or  it  may  not  be  noticed 
for  several  days  after  that  event.    It  is  a  peripheral  paralysis  and  usually 


*  American  Journal  of  the  Medical  Sciences,  Chap.  CXIII,  p.  426,  1897. 

*  Arch,  of  Gynajk.,  xxx,  2G4,  1887. 

.(40) 


OBCTETRICAL  PARALYSIS.  41 

involves  the  deltoid,  biceps,  brachialis  anticus,  supraspinatus,  infraspinatus, 
and  supinator  longus  muscles.  It  may  also  involve  the  extensor  muscles  of 
the  wrist. 

Symptoms. — The  arm  hangs  limp  at  the  side  of  the  body.  The  position 
is  governed  by  gravitation.  The  forearm  is  extended  and  pronated,  and  the 
wrist  and  fingers  flexed.  Movement  does  not  cause  pain.  The  reaction  of 
degeneration  can  be  demonstrated  when  the  paralyzed  muscles  are  exam- 
ined with  the  electric  current.  Such  examinations  are  very  difficult  in  in- 
fants having  a  thick  layer  of  fat.  At  times  very  powerful  currents  are 
necessary,  thus  provoking,  pain.  In  making  an  electrical  test,  the  normal 
arm  should  always  be  compared  with  the  affected  arm. 

Erb  demonstrated  the  fact  that  "it  is  possible  by  a  careful  examina- 
tion to  find  a  spot  two  centimeters  above  the  clavicle,  back  of  the  outer  edge 
of  the  sternomastoid  muscle,  corresponding  to  the  point  of  emergence  of 
the  sixth  cervical  nerve  between  the  scaleni,  at  which  point  irritation,  by 
the  faradic  current  will  produce  a  contraction  in  the  deltoid,  biceps, 
brachialis  anticus,  and  supinator  longus  muscles;  and  if  the  irritation  be 
increased,  the  extensors  of  the  wrist  will  also  contract.  Pressure  upon  this 
particular  region  is  often  made  during  delivery,  either  by  the  clavicle,  or 
by  forceps,  or  by  the  fingers  of  the  obstetrician.  This  is  more  common 
when  there  is  a  breech  presentation  and  the  after-coming  head  is  extracted 
in  the  common  method.  The  index  and  middle  fingers  of  the  left  hand 
being  open  like  a  fork  over  the  shoulders  of  the  child,  traction  is  commonly 
made  upon  the  shoulders,  and  the  pressure  of  the  obstetrician's  finger  in  the 
neck  often  produces  injury  of  the  plexus.  In  some  cases  injury  of  the 
plexus  is  produced  by  attempts  to  bring  down  the  hand  or  arm  in  breech 
presentations,  or  to  replace  these  when  the  head  presents.  Forceps  appli- 
cations in  an  awkward  position  may  also  produce  this  injury." 

Prognosis. — This  depends  on  the  time  when  the  treatment  is  com- 
menced. As  a  rule  paralysis  of  the  upper  arm  type  remains  three  or  four 
years.  In  a  case  of  mine  seen  recently  the  paralysis  remained  until  the 
child  was  5  years  old.  When  the  faradic  current  is  applied  and  the  muscles 
respond,  then  the  prognosis  is  good;  if  there  is  no  response,  a  cautious 
prognosis  should  be  given. 

Treatment. — The  arm  should  be  supported  with  a  sling.  Massage  aided 
by  a  faradic  current  is  sometimes  beneficial.  In  severe  cases  it  is  better  to 
use  the  galvanic  current,  using  the  mildest  current  that  will  produce  con- 
traction of  the  muscles.  If  the  child  is  old  enough  to  be  instructed,  gym- 
nastics should  be  tried  at  home  daily.  Strychnine  may  be  given  three  times 
a  day. 


CHAPTER  VI. 

ASPHYXIA  NEONATORUM  (APPARENT  DEATH  OF  THE  NEW-BORN). 

The  center  and  regulator  of  the  respiratory  movements  is  located  in 
the  medulla  oblongata.  From  it  also  is  sent  the  motor  impulse  which  gives 
rise  to  the  first  act  of  respiration. 

The  activity  of  this  center  is  believed  to  be  aiigmented  by  the  condition 
of  the  venosity  of  the  blood ;  therefore,  all  interruptions  to  placental  respira- 
tion— for  instance  the  premature  detachment  of  that  organ  or  the  com- 
pression of  the  cord — and  all  obstacles  to  the  introduction  of  air  into  the 
trachea,  such  as  mucus  or  blood,  will  be  attended  with  violent  motor  im- 
pulses: first,  efforts  to  breathe,  and  later,  convulsive  movements  producing 
death  (Boisliniere). 

There  are  two  forms  of  this  condition  usually  observed:  first,  the 
apoplectic  form  called  by  older  writers  livida,  and  second,  the  anaemic  form 
called  by  older  writers  pallida.  In  the  apoplectic  form  there  is  a  bluish 
discoloration  of  the  skin,  a  prominence  and  injection  of  the  conjunctivae, 
and  a  swollen  state  of  the  face  and  lips.  The  cardiac  pulsations  are  gener- 
ally strong,  and  the  cord  is  distended  with  blood.  In  the  anemic  form  the 
child  has  a  deadly  pallor;  the  lips  and  fingers  are  pale,  the  body  limp,  and 
muscles  relaxed.  The  heart's  action  is  inaudible,  presenting  the  condition 
known  as  asystole.  Duvergie,  in  studying  the  asphyxia  of  adults,  noted  that 
when  people  were  removed  shortly  after  an  embankment  of  earth  had  buried 
them,  they  presented  a  turgescence  of  the  face,  a  violet  hue  of  the  skin,  and 
frequent  and  regular  pulsations  of  the  heart. 

When  they  were  found  some  time  after  an  embankment  of  earth  had 
buried  them,  they  presented  a  deathly  pallor  of  the  skin,  and  the  heart  sounds 
were  usually  inaudible  or  very  feeble.  Thus  it  is  apparent  that  the  above 
conditions  of  asphyxia  present,  first,  a  mild;  and  then  a  severe  type. 

Causes. 

The  main  causes  of  asphyxia  are  due  to: — • 

1.  Compression  of  the  cord  in  a  natural  way. 

2.  Premature  detachment  of  the  placenta. 

3.  Forced  rotation  of  the  head  in  difficult  forceps  application  or  great 
contraction  of  the  uterus  in  head-last  cases,  thus  rendering  the  vessels  of 
the  uterus  impermeable  to  blood  and  suspending  the  placental  respiration. 
Another  cause  of  asphyxia  is  shortness  of  the  cord  from  its  encircling  the 
neck  tightly  after  the  head  is  born.    The  child's  face  in  this  condition  be- 

(43) 


PLATE   II 


Tho   Hyid-Dcw   ■\rctlioil   of   Aiiificial   Respiration.     A,   Extension.     B.   Somi- 
Ik'.xiou.     (',  Coni|)lclc  llcxion.      ((4ran<lin  &  Jarnian.) 


ASPHYXIA  NEONATORUM.  43 

comes  turgid  and  blue,  and  unless  relieved  the  child  will  die.  The  promptest 
treatment  consists  in  cutting  the  cord  above  the  child's  head  and  delivering 
the  infant's  body  as  quickly  as  possible.  Boisliniere  advises  the  above 
method  even  at  the  risk  of  fracturing  a  humerus. 

Sign  foe  Distinguishing  the  Stillborn  from  the  Dead. 

Bedford  Brown  says  that  the  best  means  for  distinguishing  the  still- 
born from  the  dead  is  to  be  found  in  the  temperature.  If  the  temperature 
keeps  near  the  normal,  we  must  not  cease  our  efforts  at  resuscitation,  even 
if  the  complete  suspension  of  cardiac  and  respiratory  action  has  lasted  for 
twenty  minutes  or  more;  but  if  the  temperature  of  the  child  suddenly  falls 
10,  15,  or  20  degrees  below  the  normal,  then  the  case  is  hopeless.  Another 
sign  is  the  state  of  the  pupil :  in  the  dead  the  pupil  is  widely  dilated,  in  the 
stillborn  it  is  but  little,  if  at  all  relaxed  (Therap.  Gaz.,  Vol.  XXXI, 
No.  6).  The  method  consists  in  injecting  into  each  arm  five  drops  of  whisky 
with  one  drop  of  tincture  of  belladonna.  If  the  infant  is  only  stillborn, 
the  nervous  and  circulatory  system  respond  quickly.  If  there  is  no  response 
or  only  a  very  feeble  one,  warm  sterilized  water  is  injected  under  the  skin 
(a  drachm  or  two)  and  also  about  two  drachms  with  a  drop  of  aromatic 
spirits  of  ammonia,  into  the  intestines.  After  this  dry  heat  is  applied.  If 
these  measures  fail  to  produce  a  reaction,  it  is  a  fair  test  of  the  absence  of 
vitality. 

Treatment. — If  the  child  presents  a  livid  condition  and  is  apparently 
apoplectic  with  the  cord  pulsating  strongly,  then  cut  the  cord  as  soon  as 
possible  and  allow  at  least  an  ounce  of  blood  to  escape.  Sometimes  it  is 
necessary  to  cut  the  cord  in  several  places.  If  bleeding  does  not  ensue  rap- 
idly, then  the  cord  should  be  severed  and  placed  in  warm  water  at  a  tem- 
perature of  105°  to  110°  F.    This  will  usually  stimulate  the  flow  of  blood. 

When  the  child  is  born  in  a  pallid  condition  and  feels  cold,  then  the 
cord  should  not  he  cut  until  all  pulsations  therein  have  ceased.  It  is  in  this 
condition  that  it  will  be  so  important  to  rapidly  cleanse  the  mouth,  nose, 
and  larynx  of  mucus  and  blood.  Some  authors  advise  mouth-to-mouth  suc- 
tion or  suction  made  through  a  soft  rubber  catheter  placed  in  the  larynx, 
but  these  are  usually  preliminary  means,  and  success  will  only  follow  meth- 
odical application  of  artificial  respiration. 

Byrd's  method  is  very  simple.  It  can  be  conducted  without  rough 
handling,  a  matter  of  vital  importance.  The  child's  body  rests  on  its  back 
and  is  supported  on  the  palm  surfaces  of  the  physician's  hands.  The  physi- 
cian, by  elevating  and  lowering  his  hands,  can  produce  inspiration  and 
expiration  in  a  rapid  and  efficient  manner.  This  method  is  well  worth 
trying.  An  important  point  to  remember  is  to  pull  the  tongue  forward ; 
for  this  purpose  an  artery  clamp  will  serve  in  an  emergency,  if  the  physician 
does  not  have  Laborde's  forceps  for  traction  on  the  tongue. 


44 


DISEASES  OF  THE  NEW-BORN. 


Lahorde  advises  rhytlimical  traction  upon  the  tongue  eight  or  ten  tmies 
a  minute.  This  is  a  valuable  method  and  can  be  used  while  the  child  is 
immersed  in  hot  water.  Thus  the  benefit  of  the  stimulus  on  the  tongue  will 
be  apparent  while  the  hot  bath  is  used. 

Hypodermics  of  strychnine,  ^/loo  of  ^  grain,  combined  with  5  or  10 
minims  of  whisky,  may  be  indicated.  Flushing  the  colon  with  a  pint  or 
more  of  water,  temperature  110°  or  115°  F,,  to  which  a  half-drachm  of 
alcohol  has  been  added,  may  also  aid  in  stimulating  the  circulatory  and  the 
respiratory  tract.  It  is  advisable  to  persevere  for  some  time  with  the 
above  method  of  resuscitation,  even  though  we  may  be  successful.  It  fre- 
fpiently  hapi)ens  that  new-ljorn  infants  will  respond  to  active  treatment  and 
show  signs  of  life,  but  we  must  continue  for  some  time,  or  the  respirations 

will  cease  and  the 
infant  may  die. 

A  valuable 
means  of  restoring 
suspended  anima- 
tion consists  in 
immersing  the 
new-born  infant, 
first  into  very 
Avarm  water,  and 
then  into  cold 
water.  Alternate 
fiom  hot  to  cold 
water  every  ten  or 

fifteen  seconds. 
Fig.  19. 

liilx'inont's  Tul)o   for   Inflating  the  Lung.s. 


Fig.  18. 


IXFLATIOX  OF  THE  LuNGS. 

'J'liis  method  is  sometimes  useful  when  other  means  fail.  Some  authors 
advise  the  mouth-to-mouth  method.  This  consists  in  filling  the  cheeks  with 
fresh  air  and  then  blowing  the  same  into  the  infant's  mouth.  It  can  also 
be  done  by  introducing  a  catheter  into  the  infant's  larynx.  While  the  mouth- 
to-mouth  method  is  simpler,  it  is  not  always  a  sure  way  of  inflating  the 
lungs.  Quite  frequently  the  air  will  be  bloA\Ti  from  the  mouth,  through  the 
pharynx,  into  the  stomach.  To  avoid  the  latter,  the  head  should  be  thrown 
backward,  and  compression  made  over  the  epigastrium.  If  the  nose  is  closed 
air  is  less  likely  to  enter  the  stomach. 

Mouth-to-mouth  insufTlation  of  air  is  not  devoid  of  danger.  Eeich 
reported  a  case  of  tuberculous  meningitis  due  to  attempts  at  reanimation 
by  a  tuberculous  midwife.     The  Ribemont  laryngeal  tube  is  much  safer. 


ASPHYXIA  NEONATORUM.  45 

Introducixg  a  C'atiietei;  into  the  Larynx. 

A  soft  flexible  catheter  is  more  preferable  than  a  stiff  catheter,  but  this 
requires  experience,  and  is  not  an  easy  matter  in  unskilled  hands. 

Ribemont's  tube  (Figs.  18  and  19)  is  the  best  instrument  for  inflating 
the  lungs.    It  is  inserted  like  an  intubation  tube.    It  serves  two  purposes : — 

1.  Forcing  air  into  the  lungs. 

2.  The  aspiration  of  mucus  from  the  trachea  or  bronclii. 

Great  care  should  be  used  with  any  and  all  methods.  Xo  force  is 
necessary. 


CHAPTEE  VII. 

FffiTAL  ICHTI£YOSIS. 

This  condition  is  described  by  Ballantyne,  Kyber,  Wassmuth,  and 
Carbone  as  a  skin  disease  of  the  foetus  most  probably  developed  about  the 
fourth  month  of  intrauterine  life.  It  consists  of  horny  epidermic  plates 
over  the  whole  surface  of  the  body,  separated  from  each  other  by  fissures 
and  furrows,  associated  with  certain  deformities  of  the  mouth,  nose,  eyes, 
ears,  and  extremities,  and  leading  to  the  death  of  the  infant  very  soon  after 
birth. 

It  is  a  rare  condition,  as  only  43  cases  could  be  found  in  the  whole 
literature  up  to  the  year  1895.  For  the  following  case  I  am  indebted  to 
Dr.  A.  S.  Daniel:— 

Clinical  History. — This  case  was  first  seen  five  hours  after  birth.  The  child 
had  passed  urine  and  meconium,  cried  continuously,  sleep  was  impossible.  The 
sliglitest  jar  of  the  crib  or  exposure  to  the  air  increased  the  crying.  The  respiration 
was  irregular,  the  surface  of  the  body  cold.  The  child  swallowed  with  difficulty 
and  was  fed  with  the  aid  of  a  medicine  dropper.  The  child  died  suddenly  twenty- 
four  hours  after  birth.     The  temperature  taken  soon  after  birth  was  103°  F. 

Description  of  the  Child. — There  was  no  resemblance  between  the  child  and  a 
human  being  or  any  living  thing.  The  tongue  was  the  only  part  of  the  body  that 
seemed  capable  of  motion.  The  body  presents  the  appearance  of  having  been  in  an 
integument  much  too  small  for  the  skeleton,  and  Nature  in  its  growth  had  so 
stretched  the  skin  that  it  has  the  appearance  of  being  torn  in  some  places.  Where 
it  is  torn  through,  a  purple-covered  slit  appears,  where  torn  partly  through,  a 
yellowish  colored  fissure  remains.  There  is  no  uniformity  of  arrangement  of  the 
fissures.  Fewer  are  found  on  the  back,  and  those  on  the  extremities  are  more 
shallow.  The  color  of  the  fissure,  a  purplish  red,  is  in  marked  contrast  to  the  color 
of  the  skin.  In  a  few  places  bright  blood,  is  found,  as  if  the  break  were  of  recent 
origin.  The  whole  body  is  cold  and  rigid.  The  scalp  is  divided  into  fissures  and 
numerous  irregular  conical  projections,  varying  in  size.  A  few  thin  hairs  are 
found  on  the  lateral  surface  of  the  scalp.  The  external  ears  are  replaced  by  conical 
projections.  The  palpebral  fissures  are  filled  with  purplish-red  masses;  deep  down 
in  the  sockets,  eyeballs  can  be  distinguished.  The  nose  is  flattened  and  is  identified 
by  the  widely-opened  nostrils.  The  mouth  is  open,  showing  a  non-hypertrophied 
tongue.  The  lips  are  of  a  purplish-red  color.  The  mouth  measures  5  centimeters 
in  length.  Circumference  of  head,  36.5  centimeters;  glabella  to  occiput,  18.5 
centimeters;  ear  to  ear,  15.5  centimeters.  The  neck  is  short.  Anteriorally  a 
fissure  extends  from  the  neck  to  the  umbilicus,  2  centimeters  in  width.  From  this 
fissure,  ridges  of  yellow  skin  and  purple  fissures  extend  toward  the  axillae;  they 
are  of  irregular  size  and  depth. 

The  extremities  are  rigid  and  in  the  foetal  position.  The  arms  can  be  raised 
only  at  right  angles  with  the  body.     They  cannot  be  extended  at  the  elbow.    The 

(46) 


PLATE    III 


Fatal   Fa'tal    Iclitliyosis.     Case  of   Dr.   Annie   S.  Daniel. 


FCETAL  ICHTHYOSIS.  47 

hands  are  thickened  and  the  fingers  are  rudimentary.     The  legs  are  crossed.     The 
motion  at  the  hip  and  knee  joint  is  very  imperfect.    The  toes  are  rudimentary. 

The  median  raphe  in  the  scrotum  is  faintly  marked;  testicles  are  not 
descended.  The  penis  is  Va  centimeter  in  length.  The  anus  is  open.  The  length 
of  the  foetus  is  42  centimeters,  and  its  weight  is  4  pounds  13  ounces.  In  this  case 
it  was  impossible  to  find  any  clinical  cause  for  the  disease. 

Of  the  cause  of  foetal  ichthyosis  practically  nothing  is  known.  That 
it  is  not  a  fatal  disease  in  utero  is  demonstrated  by  the  fact  that  only  one 
case  thus  far  has  been  stillborn. 


CHAPTER  VIIL 

INFLAMMA.TORY  AND  NON-INFLAMMATORY  CONDITIONSL 

Icterus  Neonatorum. 

This  form  of  icterus  is  frequently  designated  as  a  physiological  con- 
dition. It  usually  begins  on  the  second  or  third  day  after  birth,  and  may 
continue  for  a  week  or  even  a  month.  Henoch  reports  a  case  of  icterus 
brought  to  his  clinic,  which  lasted  five  weeks  and  ended  fatally.  The  ma- 
jority of  text-books  describe  this  condition  as  a  mild  disease  and  give  a  good 
prognosis.  There  are  many  theories  as  to  the  causes  leading  up  to  this 
condition.  The  haematogenic  theory  maintains  that  a  disintegration  of  red 
corpuscles  takes  place.  This  liberates  the  haemoglobin,  giving  rise  to  the 
yellowish  pigmentation. 

Racchi,  of  Naples,  disproved  the  correctness  of  this  theory  by  a  series 
of  blood  counts  which  he  reported  at  the  International  Medical  Congress 
held  at  Rome  in  1895. 

''We  can  scarcely  believe  that  the  red  corpuscles  simply  go  to  pieces  in 
the  blood,  and  that  the  products  of  such  disintegration,  floating  freely  about 
or  temporarily  lodged  in  the  tissues,  give  rise  to  the  yellow  color.  It  is  far 
more  in  accordance  with  the  workings  of  the  living  organism  to  suppose 
that  the  disintegration  takes  place  in  some  organ,  e.g.,  liver  or  spleen,  and 
if  the  products  thereof  are  floating  about,  it  is  after  passing  such  organ 
and  on  their  way  to  final  elimination.** 

Infant  F.  J.  was  seen  by  me  when  three  days  old.  Had  greenish  stools  con- 
taining mucus,  and  appeared  colicky  and  cried  considerably.  No  vomiting.  There 
was  a  universal  yellowish  pigment  of  the  body;  jaundice  well  marked;  gums  were 
yellowish;  conjunctival  mucous  membrane  showed  yellowish  pigmentation.  The 
umbilicus  was  somewhat  excoriated  and  moist  from  the  presence  of  pus.  The 
diagnosis  made  was  septic  omphalitis,  resulting  in  haematogenic  jaundice.  Very 
small  doses  of  calomel,  V,o  grain,  several  times  a  day,  were  ordered;  also  colon 
irrigations  with  chamomile  tea.  The  infant  was  nursed  by  its  mother.  Aseptic 
treatment  of  the  umbilicus  with  sterile  gauze,  cleansing  with  bichloride,  and  then 
dusting  the  parts  with  talcum  salicylicum  quickly  healed  the  inflammatory  con- 
dition. The  infant  recovered  in  about  one  week,  showing  no  sign  of  its  previous 
jaundice. 

The  following  case  is  noteworthy  owing  to  its  rarity: — 

An  infant  was  born  of  apparently  healthy  parents.  Dr.  Mehrenlander,  the 
physician  In  attendance,  stated  that  there  was  nothing  abnormal  at  the  time  of 
birth.  The  infant  weighed  about  seven  pounds.  It  was  the  fourth  child.  Three 
children  of  this  same  family  had  previously  died  on  the  third  day  after  birth.    They 


SCLEREMA    NEOXATORUM.  49 

were  to  all  appearances  healthy,  but  were  jaundiced.  Nothing  was  noticeable  with 
them  excepting  the  yellow  pigmentation  of  the  skin.  The  child  died  before  I  ar- 
rived at  the  bedside.  It  was  three  days  old.  The  skin  then  presented  a  deep  yellow- 
ish-green pigmentation,  more  marked  on  the  abdomen.  The  conjunctival  mucous 
membrane  was  deeply  pigmented.  There  was  no  inflammatory  condition  noticeable 
in  the  region  of  the  umbilicus.  The  cord  was  dressed  with  aseptic  gauze  and  no 
infection  was  suspected  from  this  channel.  The  attending  physician  suspected 
syphilis  in  the  father.  There  were  no  other  symptoms.  Neither  vomiting  nor 
diarrhoea.     A  stool  passed  before  the  infant  died,  which  looked  like  meconium. 

An  interesting  point  about  the  case  is  that  this  was  the  fourth  child  in  that 
family  which  died  of  icterus  neonatorum  a  few  days  after  birth.  The  child  died 
without  any  appai-ent  suffering,  showing  no  symptoms  of  illness.  The  temperature 
when  taken  was  normal. 

Zweifel  describes  a  series  of  cases  of  icterus  resulting  from  the  effects 
of  chloroform  passing  through  the  placenta.  The  writer  has  noted  the  asso- 
ciation of  icterus  neonatorum  in  a  large  number  of  children  born  after  a 
severe  labor,  requiring  prolonged  chloroform  narcosis.  This  may  have  been 
accidental,  yet  it  is  worth  noting. 

James  D.  Voorhees,  in  responding  to  my  question  concerning  the  asso- 
ciation of  chloroform  anesthesia  and  icterus  at  the  Sloane  Maternity  Hos- 
pital, states  that  ''all  women  receive  chloroform  at  said  hospital,  and  about 
33  per  cent,  of  the  infants  born  are  jaundiced.  All  premature  infants 
also  are  jaundiced.^* 

Sclerema  Neonatorum:. 

This  disease  is  characterized  by  a  hardening  or  thickening  of  the  skin 
and  the  subcutaneous  cellular  tissue.  The  pathological  lesions  have  been 
carefully  studied  by  Northrup.  His  case  was  a  foundling  born  amid  unsani- 
tary surroundings.  When  five  days  old  the  legs  were  swollen  and  the  feet 
as  hard  as  a  board. 

The  swelling  spread  upward,  involving  every  part  of  the  body.  The 
temperature  in  the  rectum  was  35"  C.  (95°  F.).  The  infant  died  on  the 
ninth  day.  The  body  felt  as  though  it  were  frozen.  Osier  also  describes 
this  condition  in  this  country. 

Symptoms. — An  oedema-like  swelling,  very  cold  to  the  touch,  and  very 
hard  on  palpation,  involving  circumscribed  areas,  appears  soon  after  birth. 
I  have  seen  sclerema  spread  from  the  shoulders  to  the  trunk  and  arms. 

The  infant  appears  very  sick.  The  temperature  is  subnormal  and 
recovery  is  rare. 

Was  called  to  see  an  infant  five  days  old.  Found  the  trunk  swollen,  the  hands 
and  feet  cold,  and  the  temperature  in  rectum  subnormal.  The  infant  refused  the 
breast  and  had  no  strength.  Brandy  and  water  was  prescribed.  Mustard  foot-bath 
ordered  and  one  pint  of  warm  saline  solution  injected  into  the  colon.  There  was  no 
nausea  or  vomiting.  No  retention  of  urine.  Sclerema  neonatorum  was  diagnosed. 
The  swelling  spread,  involving  the  legs  and  arms,  until  the  whole  body,  including  the 

« 


50  IXFLAMMATORY  AM)  .\().\  1X1  LAMM ATORY  CONDITIONS. 

face,  Avas   puffed  and  hard.     The  infant  could   no   longer  open   its  eyes  and  died  on 
the  ninth  day  in  convulsions. 

n.EMOGLOBIXURTA  XeOXATORUM    (WiXCKEI/s  DiSEASE)  . 

Considerable  has  been  written  upon  this  ()l)scure  condition  which  is  very 
rarely  met  with  in  the  new-born  baby.  As  a  rule  this  condition  is  seen  as 
an  epidemic  in  a  maternity  hospital.  Winckel  reports  nineteen  deaths  out 
of  twenty-tliree  cases  attacked. 

Pathology. — Haemorrhages  are  found  in  various  organs.  The  lungs  are 
black.  TIk'  bladder,  the  spinal  canal,  the  livei',  and  the  spleen  all  show 
darkened  secretions.  The  kidneys  are  dark  colored.  All  observers  state 
that  the  umbilical  vessels  are  not  involved. 

Symptoms. — The  skin  of  the  body  has  a  pecidiar  icteric  or  bronzed 
appearance.  I'he  palms  of  the  hands  and  soles  of  the  feet  have  a  bluish 
or  purplish  color.  The  conjunctiva  has  an  icteric  appearance.  The  stool 
is  blackish  or  greenish.  The  urine  is  dark  and  contains  blood;  it  is  thick 
and  sometimes  resembles  syrup.  There  is  no  fever.  The  pulse  is  very  rapid. 
Convulsions  and  squinting  are  usually  seen.  There  is  a  rapid  diminution  in 
the  Idood  cells,  from  .5,700,000  one  day  to  3,400,000  on  the  third  day. 

These  cases  end  fatally  as  a  rule. 

Acute  Fatty  Deoexeuatiox  of  the  Xew-borx^  (Buttles  Disease). 

When  an  infant  is  born  in  an  asphyxiated  condition  and  there  is  asso- 
ciated umbilical  hamiorrhage,  then  an  infection  of  pathogenic  bacteria  may 
take  place.  In  some  respects  this  disease  resembles  Winckel's  disease.  In 
both  we  have  haemorrhages  as  well  as  fatty  degeneration  of  the  internal 
organs.  The  symptoms  are  a  bleeding  from  the  stomach  and  bowels,  asso- 
ciated with  jaundice.  In  Buhl's  disease  we  have  bleeding  from  the  um- 
bilicus. 

]\Iastitis  XEOXATOi;r:\r. 

The  new-born  infant  frequently  secretes  a  fluid  in  the  mammfs.  Fe- 
males, both  human  and  animal,  occasionally  secrete  milk  without  having 
been  previously  ])regnant.  With  regard  to  the  milk  secreted  by  infants, 
there  is  some  doubt  al)out  its  real  nature.  Kollicker  does  not  view  it  as  a 
true  milk,  but  considers  its  appearance  connected  with  the  formation  of 
the  mammary  glands.     This  secretion  is  also  known  as  witch's  milk. 

Sinet}',  on  tlie  other  hand,  upon  anatomical  grounds,  considers  it  a 
true  lacteal  secretion.  It  probably  is  a  sort  of  imperfect  milk,  loaded  with 
leucocytes,  and  this  is  the  more  likely  as  Yollard'  notices  that  it  frequently 
ends  in  abscess. 


1  "Traite  des  Maladies  des  Enfants  Nouveau-nes,"  third  edition,  1837,  p.  717. 


ERYSIPELAS  IN  THE  NEW-BORN.  61 

Schlossberger  gives  an  imperfect  quantitative  analysis  of  a  sample  of 
milk  obtained  by  squeezing  the  breasts  of  a  new-bom  infant,  a  male.  In 
the  course  of  a  few  daj's  about  a  drachm  was  obtained.    The  following  was 

the  result  of  the  analysis : — - 

Water    96.75 

Fat 0.82 

Ash    0.05 

Casein,  sugar,  and  extractives 2.83 

Sugar-reaction    btrong 

The  most  complete  analysis  we  possess  of  such  milk  is  by  von  Gesner : — ■ 

Milk-fat   1.456 

Casein    0.557 

Albumin  0.490 

Mlk-sugar   0.958 

Ash    0.826 

Water  95.705 

Total  solids    4.295 

I  was  called  to  see  a  female  infant  six  days  old.  The  mother  told  me  that  the 
breasts  were  swollen  and  contained  milk.  The  same  could  be  expressed  by  gentle 
stroking  of  the  mammae.  Tlie  treatment  consisted  of  the  application  of  an  ice-bag 
and  inunctions  of:  — 

IJ  Ung.  ext.  belladonna 2  drachms 

Ung.  hydrarg.  cin 1  drachm 

Cold  cream  1  ounce 

M.    Apply  on  linen  with  tight  compresses. 

After  several  days  the  breasts  dried  and  the  swelling  disappeared. 

Another  infant,  three  weeks  old,  was  seen  by  me  recently,  in  consultation.  The 
mother  was  delivered  by  a  midwife  and  her  condition  as  well  as  that  of  the  infant 
was  apparently  normal.  The  infant's  breasts,  when  seven  days  old,  appeared  tender 
and  swollen  and  the  mother  was  advised  to  poultice  them  with  flaxseed.  This  she 
did,  and  in  addition  squeezed  the  secretion  from  the  infant's  Weasts.  This  trauma- 
tism caused  irritation,  inflammation,  and  finally  the  formation  of  an  abscess.  An 
inf'ision  was  made,  the  pus  evacuated  and  the  wound  healed  kindly. 

It  is  important  to  remember  that  the  lacteal  secretion  in  an  infant's 
breast  is  a  physiological  condition,  and  if  undisturbed  will  be  absorbed 
gradually. 

Erysipelas  in  the  New-borit. 

When  this  disease  occurs  in  the  new-born,  and  the  mother  has  a  septic 
peritonitis  or  other  infectious  disease,  the  infant  should  be  immediately 
isolated  from  the  mother.  The  symptoms  are  the  same  as  those  seen  in 
ery(=ipelas  of  older  children,  although  vomiting  and  symptoms  of  general 
sepsis  most  often  accompany  this  condition.    The  fontanel  is  depressed. 


52  INFLAMMATORY  AND  NON-INFLAMMATORY  CONDITIONS. 

Progniosis. — The  prognosis  is  usually  very  grave,  especially  so  if  the 
infant  must  be  removed  from  its  mother's  breast. 

Treatment. — The  strictest  antisepsis  must  be  used.  An  infant  should 
be  placed  under  the  care  of  a  trained  nurse,  and  all  instructions  in  regard 
to  the  hygiene  of  the  infant  must  be  strictly  carried  out.  The  general  plan 
of  treatment  is  the  same  as  that  outlined  in  the  chapter  on  "Erysipelas/' 
page  705. 

Tuberculosis  in  the  New-bokn. 

The  transmission  of  tuberculosis  from  the  mother  to  the  new-born 
is  extremely  rare.  Cases  are  on  record  in  which  the  tubercle  bacilli  were 
transmitted  from  the  mother  to  the  infant.  An  occasional  transmission  of 
tuberculosis  takes  place  through  the  placenta.  The  reason  for  the  infre- 
quency  of  this  occurrence  is  that  the  blood  of  a  tuberculous  patient  rarely 
contains  tubercle  bacilli.  Schmorl  and  Birch-Hirschfeld  believe  that  ma- 
ternal tuberculosis  can  be  transmitted,  but  not  before  the  end  of  the  fifth 
month  of  pregnancy,  and  that  the  placenta  is  always  tuberculous  wlien  the 
fcetus  is  infected.     (For  further  details  see  chapter  on  "Tuberculosis.") 

Peritonitis  in  the  New-born. 

In  the  chapter  on  "Omphalitis"  I  have  described  a  case  of  septic  infec- 
tion seen  in  consultation  practice.  The  case  recovered.  At  times  the  in- 
flammatory condition  will  extend  from  the  umbilicus  to  the  peritoneum,  and 
thus  a  septic  peritonitis  results. 

Bacteriology. — In  such  pyogenic  infections  the  streptococcus  can  be 
found.     The  bacteria  gain  entrance  directly  through  the  umbilical  vessels. 

Pathology. — The  same  lesions  affecting  the  serous  membrane,  as  the 
pleuita  and  the  pericardium,  are  found  in  the  peritoneum.  Adhesions  fre- 
quently remain. 

The  symptoms,  prognosis,  and  treatment  are  described  in  the  article 
on  "Acute  General  Peritonitis,"  Part  V. 

Pemphigus  Neonatorum.* 

This  condition  is  seen  occasionally  in  the  new-born  infant.  It  consists 
of  blebs  which  contain  yellow  serum.  In  size  they  vary  from  a  pea  to  that 
of  a  small  bean.  When  these  rupture  they  are  replaced  by  superficial  ulcers 
covered  with  a  thin  black  crust.  Sometimes  a  violet  stain  is  left  which 
may  last  for  some  time.  The  duration  of  each  bulla  is  about  one  week. 
The  location  of  the  eruption  is  on  the  palms  of  the  hands  and  the  soles  of 
the  feet.  Some  authors  regard  pemphigus  as  a  form  of  infantile  syphilis. 
The  cases  seen  by  me  have  invariably  occurred  in  poorly  nourished  children 
such  as  we  find  in  athrepsia  (marasmus). 


*  See  article  on  "Chronic  Pemphigus." 


CHAPTER  IX. 

ABNORMALITIES  AND  CONGENITAL  MALFORMATIONS. 

Angeioma. 

Circumscribed  dilatations  of  the  blood-vessels  or  capillaries  are  occa- 
sionally seen  in  the  new-born  baby.  Spongy  tumors  consisting  of  tortuous 
blood-vessels  of  a  bluish-red  color  are  usually  seen.  These  tumors  are  filled 
with  blood  and  grow  very  rapidly.  In  a  case  seen  by  me  (see  Fig.  20)  tlie 
mass  was  adherent  to  the  forehead  and  completely  obliterated  the  sight  of 
the  left  eye.  This  condition  is  one  that  can  easily  be  remedied  with  prompt 
surgical  treatment.  Some  cases  will,  if  neglected,  ultimately  result  in 
sarcomatous  degeneration. 

Treatment. — Injections  into  the  mass  of  a  5  per  cent,  nitrate  of  silver 
solution,  or  destroying  the  mass  with  a  galvanocautery,  chromic  acid,  or 


Fig.  20. — Infant  ton  months  old.  From  my  children's  soiTice  at  the 
German  Poliklinik.  The  mass  of  bluish,  tortuous  vessels  interfered  with 
the  eyesight.  Blccdiii}^  was  very  easily  provoked.  Surgical  treatment  is 
the  only  means  of  eiadicating  the  mass.     (Original.) 

(53) 


54  ABNORMALITIES  AND  CONGENITAL  MALFORMATIONS. 

nitric  acid  are  most  generally  used.  A  good  plan  is  to  first  apply  pure 
carbolic  acid,  after  which  the  fuming  nitric  acid  should  be  used.  This 
latter  method  is  painless  and  effective. 

Harelip. 

This  congenital  deformity  is  frequently  seen  in  children.  Sometimes 
it  is  simply  "a  slight  indentation  in  the  lip,  or  the  fissure  may  extend  to 
the  nostril."    The  treatment  is  surgical. 


Fig.  21.— Harelip  Nipple,' 

Cleft  Palate. 

This  abnoniiality  is  frequently  seen  in  children.  While  the  soft  p:ilate 
only  may  be  atfected,  it  not  infrequently  iiappciis  that  the  fissure  extends 
througli  ilio  linrd  ijalatc,  tlius  causing  a  wide  gap  in  the  roof  of  the  mouth. 

Feeding  Children  AlSiicted  with  Cleft  Palate. — An  infant  born  with 
cleft  palate  has  a  greater  struggle  for  existence  than  a  child  born  healthy, 
M'ithout  this  deformity.  It  is  advisable  to  give  the  best  possible  food,  and, 
therefore,  breast-milk  only  should  be  used.  The  milk  should  be  drawn  from 
a  woman's  breast  by  means  of  a  breast-pump,  as  described  in  the  section  on 
"Specimen  of  Breast-milk  for  Chemical  Examination." 

An  artificial  nipple  should  l)e  attached  to  the  feeding-bottle,  and  to  the 
former  should  be  attached  a  flap  of  India  rubber  so  made  that  it  fits  the 
roof  of  the  mouth.  The  pressure  of  the  nipple  against  the  piece  of  rubber, 
when  in  position,  converts  it  into  an  artificial  palate-picco,  and  prevents 
the  escape  of  the  milk  into  the  nose  during  the  effort  of  swallowing.  Tliis 
shield  is  chosen  to  avoid  permitting  curdled  milk  to  pass  into  the  recesses 
of  the  turbinated  bones  and  to  cause  aphthous  patches.     (See  Fig.  21.) 

It  is  advisable  to  operate  on  an  infant  for  this  deformity  between  the 
third  and  sixth  months  of  its  life,  if  sufficient  progress  in  its  development 
Avill  warrant  it. 

When  the  al)ove  method  of  feeding  is  not  satisfactory  and  the  child 
shows  evidences  of  starvation,  then  we  must  resort  to  gavage.  (See  cha])ter 
on  "Gavage.") 

Our  aim  should  be  to  build  up  the  infant  from  its  birth,  with  breast- 
milk  if  obtainable.     In  one  case  known  to  me  the  breast-milk  was  pumped 


'This  harelip  nipple  can  be  procaued  from  the  Miller  Rubber  Manufacturing  Co., 
Akron,  Ohio. 


CONGENITAL  ADENOIDS.  55 

off  every  four  hours  and  the  infant  was  nourished  by  gavage  with  this  milk. 
When  breast-milk  is  not  obtainable,  then  properly  modified  milk  should  be 
used,  to  conform  with  the  age  and  requirements  of  the  child.  If  the  child 
does  not  assimilate  its  food  properly,  the  operation  should  be  postponed  until 
the  child  is  built  up  and  strong  enough  to  stand  the  operation;  hence  the 
guide  for  estimating  the  time  for  the  operation  is  dependent  more  on  proper 
feeding  than  on  any  other  factor. 

Hygienic  measures  are  very  important  as  the  irritation  by  food  will 
frequently  cause  inflammation  in  the  mouth.  For  details  of  the  surgical 
treatment  the  reader  is  referred  to  the  many  good  text-books  on  operative 
surgery. 

Tongue-tie  (Adh^sia  Lingua). 

Tongue-tie  consists  of  an  abnormally  short  frsenum.  In  some  instances 
it  may  interfere  with  nursing,  and  possibly  with  speaking.  It  is  one  of  the 
most  trivial  disorders  of  infancy. 

Treatment. — Incise  the  frsenum  near  its  attachment  to  the  tongue  with 
a  pair  of  curved  scissors.  The  incision  may  be  enlarged  with  the  aid  of 
some  dull  instrument.  Some  authors  advise  using  the  finger-nail,  which 
latter,  however,  is  not  aseptic.  A  tongue-tie  should  not  be  operated  upon 
if  an  infection  exists  in  the  immediate  surroundings. 

The  after-treatment  consists  in  using  a  bland  mouth  wash,  such  as  a 
1  per  cent,  listerine  solution,  or  1  per  cent,  alum  solution,  especially  after 
feeding  the  child. 

Congenital  Adenoids. 

We  occasionally  meet  with  infants  in  which  this  condition  exists.  This 
mechanical  impediment  prevents  breathing  through  the  nose.  An  infant, 
therefore,  is  at  a  great  disadvantage,  because  it  cannot  breathe  while  nurs- 
ing.   The  following  case  will  serve  to  illustrate  this  condition : — 

I  was  called  to  see  an  infant,  Mary  W.,  in  consultation.  The  attending  physi- 
cian gave  me  the  following  history:  The  infant  is  twenty  days  old  and  weighs  6 
pounds  and  14  ounces.  At  birth  she  weighed  7  pounds.  She  was  nursed  at  the 
mother's  breast  for  about  one  week.  The  infant  seemed  to  dislike  the  breast,  as  she 
would  draw  and  immediately  let  go  of  the  nipple.  The  mother  believed  the  infant  did 
not  like  the  taste  of  her  milk.  A  wet-nurse  was  procured,  and  the  same  trouble  was 
encountered;  the  infant  would  take  one  swallow  and  then  let  go  of  the  nipple  in 
order  to  get  her  breath.  A  nipple-shield  was  then  used,  but  the  same  difficulty  was 
encountered.  The  family  believed  that  the  infant  did  not  like  breast-milk,  so  she 
was  given  bottle  feeding.  She  took  the  nipple  of  the  bottle,  drew  quite  well,  and 
then  let  go,  when  it  was  necessary,  for  respiration.  I  ordered  spoon  feeding  and  this 
worked  quite  well.  The  breast-milk  was  pumped  from  the  wet-nurse  and  fed  by 
spoon.  This  method  was  successful.  The  child  swallowed  a  spoonful  of  milk  and 
then  had  a  chance  to  breathe.  An  examination  of  the  rhino-pharynx  revealed 
adenoids.  These  were  removed  witli  the  aid  of  a  sharp  spoon,  and  three  days  later 
normal  conditions  existed. 


66  ABNORMALITIES  AND  CONGENITAL  MALFORALA.TIONS. 

The  infant  was  again  put  to  the  breast  when  six  weeks  old  and  continued  to 
nurse  successfully  for  six  months.  She  was  then  weaned,  owing  to  the  illness  of 
the  wet-nurse.  Cows'  milk  was  substituted.  The  child  is  to-day  a  perfectly 
healthy  little  girl. 

Peotkusion  of  the  Ears. 

Protrusion  of  the  ears  is  frequently  seen  in  children.  The  anxious 
mother  will  consult  the  physician  regarding  the  treatment.  These  cases  are 
easily  managed  in  very  young  infants.  A  fenestrated  cap,*  closely  fitting  to 
the  head  so  that  the  ears  are  well  held  back  in  their  normal  position,  has 
served  me  very  well.  Young  infants  object  to  having  their  heads  covered, 
but  soon  become  accustomed  to  this  cap,  as  it  is  only  worn  at  night  and 
removed  in  the  morning.  It  is  advisable  to  change  the  cap  frequently,  as 
some  children  perspire  from  its  use.  It  must  be  worn  for  months  before  any 
benefit  is  noted. 

In  very  severe  cases  in  which  the  above  treatment  is  not  successful,  it 
may  be  necessary  to  call  in  the  surgeon.  The  operation  is  a  simple  one  and 
the  result  is  excellent. 

Abnormalities  of  the  Air  Passages. 

When  there  is  deficient  oxygenation  of  the  lungs,  collapse  frequently 
occurs,  and  is  called  atelectasis  pulmonum.  This  condition  is  due  to  the 
unaerated  condition  of  the  vesicles.  The  trouble  is  usually  found  in  the 
nasopharynx  in  the  form  of  adenoids,  unless  some  rare  malignant  condition 
is  present. 

Many  pigeon-breasted  children — with  apparent  rachitic  manifestations 
of  the  thorax — owe  this  anatomical  peculiarity  more  to  improper  oxygena- 
tion of  the  lungs  than  to  improper  feeding.  In  such  children  it  is  not  rare 
to  meet  with  congenital  adenoids.  (Kead  article  on  "Congenital  Ade- 
noids.") 

It  is  to  l)e  understood  that  changing  the  food  or  giving  restorative  treat- 
ment, such  as  iron  or  codliver-oil,  cannot  cure  such  a  child  until  the  cause 
is  eradicated. 

Congenital  Stenosis  of  the  Larynx. 

In  the  chapter  on  "Inherited  Syphilis"  I  describe  a  case  of  syphilitic 
stenosis  of  the  larynx,  which  necessitated  a  tracheotomy.  Several  years  ago 
a  child  was  brought  to  my  clinic  suffering  with  cyanosis  and  difficult  breath- 
ing. Intubation  was  tried  without  affording  any  relief.  As  a  last  resort 
tracheotomy  was  performed,  but  this  afforded  no  relief.  A  post-mortem 
examination  showed  that  we  were  dealing  with  a  diverticulum  of  the  trachea. 
In  addition  thereto  the  larynx  and  trachea  were  lined  with  a  series  of  syph- 
ilitic ulcerations. 


» This  cap  can  be  procured  at  Best  &  Co.'s,  West  Twenty-third  Street,  N.  Y, 


CEPH  A  lilLEMATOMA.  57 

Prominent  Sternum. 

This  is  frequently  called  pigeon-breast.  It  is  usually  seen  in  older 
children.  It  is  occasionally  seen  as  a  result  of  Pott's  disease,  but  more  fre- 
(|uently  it  is  associated  with  rickets.  It  has  been  described  by  me  in  the 
chapter  on  "Eachitis.'' 

Depressed  Sternum. 

Congenital  depression  of  the  sternum  is  occasionally  seen  in  very  young 
infants.  It  is  more  frequently  seen  as  a  funnel-shaped  depression,  and  is  a 
symptom  of  structural  weakness.  It  more  often  accompanies  a  general 
rachitic  manifestation  to  which  I  call  attention  in  the  chapter  on  "Rachitis." 

HEMATOMA  OF   THE    StERNO-MASTOID. 

During  labor  traumatic  conditions  frequently  induce  haemorrhages. 
These  conditions  are,  therefore,  seen  in  natural  labor  with  very  large  chil- 
dren, or  when  forceps  are  used.  Pressure  is  cited  by  most  authors  as  one  of 
the  causes  of  this  condition.  Henoch  believes  that  hsematoma  of  the  sterno- 
mastoid  is  caused  by  twisting  the  head  during  labor.  The  swelling  is  due 
to  an  extravasation  of  blood  and  to  inflammatory  conditions  of  the  muscle. 
It  is  rarely  seen  before  the  child  is  two  or  three  weeks  old.  There  is  no 
treatment  necessary.  The  blood  is  absorbed  and  the  swelling  gradually 
disappears. 

Cephalhematoma  . 

A  swelling  is  sometimes  seen  on  the  top  of  the  head  during  the  first 
few  days  of  the  infant's  life.  It  is  usually  associated  with  the  application 
of  forceps  or  a  similar  injury  during  labor.  This  condition  is  rare  in  chil- 
Qren.  The  statistics  of  the  Sloane  Maternity  Hospital  show  that  this  con- 
dition was  met  with  in  20  out  of  1300  consecutive  births,  or  1.6  per  cent. 
There  may  be  several  swellings.  They  are  most  frequently  seen  over  the 
parietal  or  occipital  bone. 

Symptoms. — A  swelling  that  is  very  soft  and  fluctuating  is  noticed. 
This  swelling  gradually  increases  in  size,  and  attains  its  maximum  at  the 
end  of  twelve  or  fourteen  days.  There  is  no  pulsation  palpable.  The  tem- 
perature is  usually  normal. 

Diagnosis. — This  condition  is  frequently  mistaken  for  encephalocele. 
The  latter,  however,  is  always  seen  in  conjunction  with  the  fontanel  or  along 
the  line  of  the  sutures. 

Pressure  causes  cerebral  symptoms.  This  condition  can  be  confounded 
with  hydrocephalus.  In  the  latter  the  symmetrical  enlargement  of  the  whole 
head  is  always  a  characteristic  feature. 


58  ABNORMALITIES   AiND   CONGENITAL   MALFORMATIONS. 

Baby  M.,  seven  days  old,  was  born  with  the  aid  of  forceps,  after  a  very  diffi- 
cult and  dry  labor.  When  the  infant  was  three  days  old  a  swelling  was  noticed  on 
the  scalp  over  the  left  parietal  bone.  This  swelling  gradually  increased  in  size  and 
felt  soft,  doughy,  and  fluctuating.  An  incision  was  made  which  liberated  about  four 
ounces  of  clear,  fluid  blood.  Several  days  later  this  case  was  also  seen  by  Dr.  Willy 
Mej'er,  and  as  suppuration  existed  it  was  necessary  to  treat  the  wound  on  general 
surgical  principles.     The  child  recovered. 

Treatment. — The  above  case  illustrates  the  mistake  that  can  be  made. 
A  hematoma  is  a  benign  condition  and  disappears  without  treatment. 
Bandaging  and  compression  are  unnecessary,  but  injury  to  the  part  must 
be  avoided. 

Caput  Succedaneum   (Spurious  Cepiialh.ematoma : 
Supplementary  Head). 

This  is  a  swelling  of  the  scalp  due  to  congestion,  resulting  in  an  ex- 
travasation of  the  blood  and  lymph  into  the  subcutaneous  tissue  which  is 
external  to  the  pericranium.  This  swelling  does  not  fluctuate.  It  is  usually 
seen  in  that  portion  of  the  head  which  first  presents  itself  at  the  vulva  dur- 
ing labor.  No  treatment  is  required,  as  this  condition  usually  becomes 
normal. 

Congenital  Cyst  of  the  Kidney. 

The  literature  records  an  occasional  case  of  this  condition.  There  are 
no  symptoms  which  would  be  the  means  of  determining  this  condition  dur- 
ing life.    The  diagnosis  is  therefore  made  post-mortem. 


Fig.   22. — Congenital   Cystic  Kidney,  half  natural   size.      ( Langerhans. ) 

Congenital  Sacral  Tumor. 

J.  B.,  male  infant,  eleven  months  old,  was  brought  to  my  children's  service 
at  the  German  Poliklinik.  He  was  breast-fed  and  appeared  in  good  health.  The 
mother  noticed  a  large  swelling  over  the  sacral  and  lumbar  regions.     The  infant  did 


CONGENITAL  MALFORMATIONS  OF  THE  RECTUM.  59 

not  seem  to  be  in  pain.  The  growth  was  non-inflammatory  and  did  not  interfere 
with  the  movements  of  the  legs.  The  diagnosis  of  congenital  lipoma  was  made  and 
an  operation  advised.  The  case  was  sent  by  me  to  Dr.  Geo.  F.  Shrady  for  operation 
at  St.   Francis  Hospital.      The  tumor  was  removed.     The  case  recovered. 


Fig.  2-j. — Congenital  Sacral  Tumor.      (Original.) 

Congenital  Malformations  of  the  Eectdm. 

E.  E.  Kirby^  states  that  these  occur  under  the  following  types: — 

1.  Congenital  narrowing  of  the  anus  or  rectum,  without  complete 
occlusion.  The  anal  aperture  is  at  times  preternaturally  small,  either  in 
consequence  of  a  contraction  of  the  lower  end  of  the  rectum,  or  from  the 
fact  that  the  skin  may  extend  occasionally  over  the  border  of  the  anal  mar- 
gin. The  diagnosis  is  usually  easy,  for  the  contraction  is  near  the  anus  and 
can  be  readily  detected  by  the  finger,  or  seen  when  due  to  a  fold  of  skin 
extending  across  the  anus.    The  treatment  consists  in  dividing  the  ring  or 

"i^kin  on  the  dorsum,  and  daily  dilatation,  either  with  the  finger  or  soft  rubber 
bougie. 

2.  Closure  of  the  anus  by  a  membranous  diaphragm  (atresia  of  the 
anus;  is  the  simplest  of  all  forms  of  congenital  malformations,  and  is  treated 
by  a  crucial  incision  through  the  membrane. 

3.  In  imperforate  rectum  one  may  expect  to  find  some  of  the  most  diffi- 
cult cases  of  malformation,  although  some  are  comparatively  simple.  In- 
stead of  a  normal  anus  the  skin  of  the  perineum  extends  across  the  anal 
region  from  side  to  side,  and  the  rectum  may  terminate  quite  a  distance 
from  the  normal  site  of  the  anus.  The  intervening  space  may  be  made  up 
of  coDnective  tissue,  while  a  circular  elevation  or  depression  marks  the  nor- 
mal site  of  the  anus.     Occasionally  a  distinct  fibrous  cord  may  be  traced 


'Congenital  Rectal  Malformations."     Archives  of  Pediatrics,  August,  1897. 


60  ABNORMALITIES  AND  CONGENITAL  MALFORMATIONS. 

from  the  rectal  pouch  to  the  skin.  If  the  rectal  pouch  be  not  at  too  great 
a  distance  from  the  skin,  a  sense  of  fluctuation  may  be  felt  by  firm  pressure 
of  one  finger  over  the  anus  and  the  hand  over  the  abdomen. 

4.  The  system  which  separates  the  anal  and  rectal  pouches  in  cases  of 
imperforate  rectum  with  a  normal  anus  is  generally  within  easy  reach  of  the 
anus.  It  may  be  perforated  and  slow  dribbling  of  meconium  allowed.  There 
may  also  be  more  than  one  septum. 

5.  The  anus  may  be  absent  and  the  rectum  open  at  any  point  in  the 
perineum  or  sacral  region.  The  lower  portion  of  the  rectum  in  these  cases 
is  usually  of  a  fistulous  character,  lined  by  true  mucous  membrane,  and  the 
abnormal  anus  is  always  narrow  and  insufficient  for  its  purpose.  Occasion- 
ally the  rectum  terminates  in  two  distinct  openings,  at  a  greater  or  less 
distance  from  each  other. 

6.  The  anus  may  be  absent  and  the  rectum  terminate  in  the  bladder, 
urethra,  or  vagina.  In  females  the  vaginal  opening  is  the  most  common; 
in  males  the  vesical.  This  condition  is  usually  rapidly  fatal  unless  relieved 
by  prompt  surgical  interference. 

7.  The  rectum  or  the  large  intestine  may  be  entirely  absent. 
Kirby  lays  down  the  following  rules: — 

1.  An  operation  should  always  be  performed,  and  performed  without 
delay. 

2.  If  there  be  any  chance  of  establishing  an  opening  at  the  normal  site 
of  the  anus,  the  surgeon  should  at  first  direct  his  attention  to  this  procedure. 

3.  The  use  of  a  trocar  as  an  aid  in  finding  the  rectal  pouch  before  or 
after  incision  through  the  perineum  is  not  sanctioned  by  modern  surgical 
authority. 

4.  The  result  of  attempts  to  establish  an  outlet  for  the  imperforate 
rectum  through  the  perineum  are  not  favorable  as  regards  the  production 
of  a  useful  anus. 

5.  In  case  of  failure  to  establish  a  new  anus  in  the  anal  region,  colotomy 
should  at  once  be  performed. 

6.  In  the  formation  of  an  artificial  anus  the  left  groin  is  the  best  site 
for  the  operation. 

7.  Attempts  at  establishing  an  anus  in  the  anal  region  after  a  colotomy 
are  attended  with  great  danger,  and  are  generally  unsuccessful. 


PART  III. 

FEEDING  IN  HEALTH  AND  DISEASE. 


CHAPTER  I. 
BREAST-MILK  AND  WET-NURSING. 

Colostrum. 

ColostrTim  is  found  in  the  breast  of  a  woman  several  hours  after  giving 
birth  to  her  baby.     It  resembles  milk^  but  is  a  much  thinner  fluid.     It  is 


a9 


o 


COLOSTRUIM- 
CORPUSCLES 


*Fig.  24. — From  a  drop  of  milk  on  the  third  day  after  delivery,  kindly 
furnished  by  Dr.  H.  L.  CoUyer,  showing  colostrum  corpuscles.  The  specimen 
drawn  by  Dr.  Julian  W.  Brandcis.      (Zeiss  Ocular  4,  dd  Lens.)      (Original.) 

always  the  forerunner  of  a  healthy  normal  secretion  of  breast-milk,  which 
usually  appears  on  the  third  day  after  the  birth  of  the  infant. 

Colostrum  corpuscles  have  been  described  by  Czerny  as  lymphoid  cells, 
whose  function  is  to  absorb  and  reconstruct  unused  milk  globules  and  to 
convey  them  from  the  milk-glands  into  the  lymph-channels.  These  cor- 
puscles usually  disappear  in  one  week  or  ten  days  after  birth.  When  colos- 
trum corpuscles  are  present  after  one  month,  then  such  milk  will  cause 
gastric  disturbances.  It  is  a  wise  plan  to  examine  the  milk  microscopically 
whenever  the  slightest  evidence  of  gastric  or  intestinal  disturbance  is  noted. 

According  to  Baginsky,  colostrum  contains  large  quantities  of  serum- 
albumin,  and  is  also  very  rich  in  fat  and  colostrum  corpuscles,  and  contains 

'  From  "Infant  Feeding  in  Health  and  Disease."     Louia  Fischer,  Third  Edition. 

(61) 


62 


INFANT  FEEDING. 


Appearance. 
Specific  Gravity. 
Reaction. 

On  Boiling. 
Coagulates. 


Table  No.  8.^ 
Properties  of  Human  Milk. 

Bluish,  semitransparent,  no  odor,  sweetish. 

1026  to  1036. 

Amphoteric,  relation  of  alkalinity  and  acidity  as  3  to  1. 

(  Does  not  coagulate,  and  forms  a  very  thin,  hardly-per- 
l      ceptible  skin. 

At  ordinary  temperature  after  several  hours. 


Coagulates   on   addi- 

,.  f     T    }  f   •      J  Coagulates   imperfectly   in   small    isolated   flakes,   which 

do  not  precipitate  as  a  uniform  coagulura. 


ment. 


Fat. 


Yellowish  white,  resembling  cow-butter.     Specific  gravity 
at  15°  C,  0.9G6.     Melts  at  34°  C. 


Varieties  of   Fat.  Butyrin,  palmitin,  stearin,  olein,  myristin,  caproin. 

J  Few  vola 
I      consist 


Behavior    of     Various  f  Few  volatile  acids,     ^lore  than  half  of  the  non-volatile 

of  oleic  acid. 


Acids. 


{Difficult  to  precipitate  with  acids  and  salts.  The  pre- 
cipitate redissolves  in  excess  of  acids.  During  pepsin 
digestion  there  is  no  pseudonuclein  produced. 

f  Lactalbumin  and  lactoglobin ;   relation  of  casein  to  albu- 
Composition    of   Albu- j       min,    0.5    to    1.2    or    1    to   2.4;    of    the    1.3    per    cent, 
minoids.  |       albumin,   there  are   64   parts  of  casein,   and  37   parts 

L      of  globulin  and  albumin. 


Solids. 


Quantitative    Analy 

sis 
Soxl 


iniitaiive    Anaiv-  r 

,.  :  Water,  87.41;   albu 

IS,     according    to  -{ 

.   ',  ,  ^  ^  j       0.21;   solids,  0.31 

loxhlet.  ^ 


Less  solids  than  in  cows'  milk,  especially  CaO — PjOj. 

)uminoids,   2.20;    fat,   3.78;    milk-sugar, 


Bacteria. 


Usually  sterile,  rarely  staphylococcus  albua  and  aureus. 


'  Fi-om  "Infant  Feeding  in  Health  and  Disease."      Loviis  Fischer,  Third  Edition. 


PROPERTIES  OF  COWS'  MILK. 


63 


Appearance. 
Specific  Gravity. 

Reaction. 

On  Boiling. 

Coagulates. 

Coagulates  on  addi- 
tion of  Lab-fer- 
ment. 


Table  No.  8a. 
Properties  of  Cows'  Milk. 

(  Opaque  white   or   whitish   yellow,   in  thin   layers   bluish 
(      white,  slight  odor,  faintly  sweet. 

1028  to  1036. 

(Amphoteric;  relation  between  alkalinity  and  acidity, 
2  to  1;  Soxhlet  maintains  that  cows'  milk  contains 
three  times  the  acidity  of  human  milk. 

(  Does  not  coagulate  and  forms  a   skin  containing  casein 
i      and  lime-salts. 

Coagulates  very  soon,  owing  to  lactic-acid  formation. 

Coagulates  to  a  solid  mass  at  body-temperature,  from 
which  a  yellowish  fluid  can  be  expressed. 


Fat. 


Varieties  of  Fat. 


Behavior    of    Various 
Acids. 


Yellowish-white  mass.     Sp.  gr.  at  1.5°  C,  0.949  to  0.990. 

fPalmitin,  olein,  stearin,  myristin,  caprilin,  caprin, 
caproin,  butyrin,  laurin,  lecithin,  cliolesterin,  and  yel- 
low coloring  matter. 

Volatile  fatty  acids,  about  70  per  cent.;  not  volatile, 
0.3  to  0.4  per  cent,  of  oleic;  the  remainder  consists  of 
palmitic  and  stearic  chiefly. 


Milk-plasma  Casein. 


Composition    of   Albu 
minoids. 


Solids. 

Quantitative  Analy- 
sis, according  to 
Soxhlet. 


(  Easy  to  precipitate  with  acids  and  salts;  excess  of  acid 
\      does  not  dissolve;  belongs  to  the  nucleo-albumin  group. 


/ 


Less  lactalbumin  and  globin;  the  largest  portion  of  the 
%  albuminoids  is  casein.  Relation  of  casein  to  albumin, 
I       0.3  to  3.0,  or  1  to  10. 

Cows'  milk  contains  more  solids  than  human  milk. 

Water,  87.17;   albuminoids,  3.55;   fat,  3. 09;   milk-sugar, 
4.88;  solids,  0.7L 


Bacteria. 


■  Contains  all  milk  bacteria,  frequently  al.so  pathogenic 
bacteria,  as  typhoid,  diphtiieria,  and  tubercle  ba- 
cilli, etc. 


64  INFANT  FEEDINQ. 

a  large  quantity  of  salts.  The  last  two  ingredients  are  supposed  to  be  the 
cause  of  the  laxative  action  of  the  colostrum. 

When  colostrum  corpuscles  persist  in  breast-milk,  in  spite  of  the  regu- 
lated diet  and  the  hygienic  condition  of  the  mother,  then  breast-feeding 
must  be  discontinued.  A  very  fretful  and  nervous  mother  will  frequently 
have  colostrum  corpuscles  in  her  milk.  An  instance  of  this  kind  was  seen 
recently  by  me.  Substitute  feeding  will  frequently  modify  this  condition 
unless  there  is  a  specific  cause  for  the  same.  When  a  nursing  mother  is 
very  weak  and  anemic  after  her  confinement,  then  iron  is  indicated.  I  saw 
a  case  in  consultation  recently  in  which  the  combined  use  of  fresh  air, 
cereals,  and  iron  changed  a  thin  milk  containing  colostrum  corpuscles  into 
a  thick  creamy  milk  in  less  than  one  month.  Continued  menstruation  or 
uterine  disorder  with  disease  in  the  endometrium  may  cause  profound 
anaemia  and  thus  render  breast-milk  very  thin.  Such  milk  is  totally  unfit 
for  the  proper  nutrition  of  the  infant. 

An  analysis  of  colostrum  milk  of  a  cow  by  Harrington  gave  the  fol- 
lowing results  (Rotch)  : — 

Fat 1.71 

Milk-sugar  4.90 

Proteids   1.72 

Ash    0.79 

Total  solids    9.12 

Water  90.88 


100.00 


The  table  which  follows  represents  the  analysis  of  the  five  specimens 
of  human  colostrum  milk,  also  made  by  Harrington ; — 

Table  No.  9. 

I           II           III  IV         V 

Fat 1.40        0.68        2.40  5.73  4.40 

Milk-sugar  and  proteids 9.44  11.53  11.15  10.G9  11.27 

Ash    0.17        0.31        0.25  0.16  0.21 

Total  solids  11.01       12.52      13.80      16.58       15.88 

Water   88.99      87.48      86.20      83.42      84.12 

100.00     100.00     100.00     100.00    100.00 

Breast-milk. 

According  to  Pfeiffer,  human  milk  contains,  several  days  after  the 
birth  of  the  baby,  a  large  quantity  of  albumin,  salt,  and  a  small  quantity 
of  fat.  He  also  found  that  the  longer  the  period  of  nursing  the  smaller  the 
quantity  of  albumin,  which,  in  the  eleventh  month,  sinks  quite  low.    There 


PLATE  IV 


A  Drop  oi  Xoinial  liieast-milk  from  a  Primfpara.      (Original.) 


WOMAN'S  MILK. 


65 


is  also  a  decrease  in  the  quantity  of  salts,  whereas  the  amount  of  sugar 
steadily  increases.  The  fat  varies  constantly.  According  to  Johaunessen, 
the  quantity  of  albumin  in  the  first  six  months  is  1.192  per  cent.;  in  the 
next  six  months  0.989  per  cent, ;  and  at  the  end  of  the  year  0.907  per  cent. 

Breast-milk  varies  according  to  the  length  of  time  that  it  remains  in 
the  breast,  and  also  the  length  of  the  nursing  period ;  so  it  has  been  shown 
that  the  first  milk  taken  at  the  beginning  of  the  nursing  act  is  the  poorest 
in  nutrient  value,  whereas  the  last  milk  is  richest  in  fat.  The  longer  the 
milk  remains  in  the  glands  of  the  breast,  the  more  will  the  solid  substances 
of  the  same  be  absorbed,  so  that  only  a  watery  solution  remains.  If  sucking 
is  commenced,  this  stimulation  soon  changes  the  character  of  this  watery 
milk,  so  that  normal  milk  will  soon  be  secreted.  Forster  studied  the  chem- 
ical constitution  of  the  first,  middle,  and  the  last  portions  of  milk  from  a 
nursing  woman,  with  the  following  result. 

In  one  hundred  parts  he  found : — - 

Table  No.  10. 


First  Portion  of  the 
Nursing  Act. 


Second  Portion  Dur- 
ing Nursing. 


Ttiird  Portion  at  the 
End  of  the  Nursing 
Act. 


Water 

Nitrogenous  Substances 

Fat 

Sugar 

Ash 


90.24 
1.13 
1.70 
5.56 
0.46 


89.68 
0.94 
2.77 
5.70 
0.32 


87.50 
0.71 
4.51 
5.10 
0.28 


The  quantity  examined  was  37.3  grams. 

From  a  study  of  the  foregoing  tables  we  find  a  decrease  of  nitrogenous 
substances  during  the  course  of  the  nursing,  a  steady  increase  in  the  amount 
of  fat,  and  an  unvarying  percentage  of  sugar.  Thus,  it  is  apparent  that,  in 
order  to  submit  a  specimen  of  hreast-milk  to  a  chemical  examination,  it  is 
necessary  to  stimulate  the  secretory  functions  of  the  mammary  glands  by 
putting  the  child  to  the  breast  at  least  two  minutes;  thus  an  even  milk  can 
be  procured.  If  this  rule  is  overlooked,  then  we  shall  find  proportions  in 
the  chemical  components  of  milk  which  might  otherwise  be  entirely  dif- 
ferent. The  most  recent  chemical  analysis  of  breast-milk  shows  that  in  a 
hundred  parts  there  are: — 

Solids    11.5 

Liquids   88.5 

Of  the  solid  constituents  there  are: — 

Casein    1.2  to  1.03 

Albumin     0.5 

Fat    0.8  to  4.07 

Milk-sugar    6  0  to  7.03 

Ash   0.2  to  0.21 

e 


66 


INFANT  FEEDING. 


The  above  is  the  chemical  examination  of  a  good  average  breast-milk. 
I  again  call  attention  to  the  fact,  however,  that  not  only  does  the  milk  vary 
in  different  women,  but  it  also  varies  in  the  same  woman  during  one  single 
nursing  act. 

The  albuminoids  of  milk  consist  of  real  casein,  lactalbumin,  globulin, 
and  opalisin.  This  latter  body  has  only  recently  been  discovered  by  A. 
VVroblewski,  and  more  recently  by  Schlossmann. 

Phosphorus  exists  in  milk  as  nuclein-phosphorus.  Wittmaack  has 
demonstrated  the  fact  that  the  phosphorus  in  woman's  milk  exists  as  an 
organic  nitrogen  compound  in  the  casein. 

According  to  the  examination  of  Stolasa,  lecithin  contains  a  larger 
quantity  of  phosphorus  in  woman's  milk  than  in  cows'  milk. 

The  specific  gravity  of  breast-milk  varies  from  1026  to  1036. 

The  Mammary  Glands. — The  mammary  glands  of  the  same  woman 
may  yield  somewhat  different  milk,  as  shown  by  Sourdat  and  later  by 
Brunner.  Also  the  different  portions  of  milk  from  the  same  milking  may 
have  different  compositions.  The  first  portions  are  always  poorer  in  fat 
(Parmentier,  Peligot,  and  others). 

According  to  I'Heritier  Vernois  and  Becquerel,  the  milk  of  blondes 
contains  less  casein  than  that  of  brunettes :  a  difference  which  Tolmatscheff 
could  not  substantiate.  Women  of  weak  constitutions  yield  a  milk  richer  in 
solids,  especially  in  casein,  than  women  with  strong  constitutions. 

According  to  Vernois  and  Becquerel,  the  age  of  the  woman  has  an  effect 
on  the  composition  of  the  milk,  so  that  we  find  a  greater  quantity  of  proteids 
and  fat  in  women  15  to  20  years  old  and  a  smaller  quantity  of  sugar.  The 
smallest  quantity  of  proteids  and  the  greatest  quantity  of  sugar  are  found 
at  20  or  from  25  to  30  years  of  age.  The  milk  with  the  first-born  is  richer 
in  water — with  a  proportionate  diminution  of  the  quantity  of  casein,  sugar, 
and  fat — than  after  several  deliveries.  The  influence  of  menstruation  seems 
to  slightly  diminish  the  milk  sugar  and  to  considerably  increase  the  fat  and 
casein. 


Fig.  25. — Heeren's  Pioscop,  for  Optical  Milk  Test. 

Pioscop. — One  drop  of  milk  can  be  examined  in  the  pioscop  and  com- 
pared with  the  colors  on  the  same.  This  is  a  rapid  but  rough  method  of 
estimating  the  richness  of  the  milk. 


WOMAN'S  MILK. 


67 


Specimen  of  Breast-milk  for  Chemical  Examination.  —  After  the 
third,  possibly  the  fourth,  day  the  average  healthy  woman  secretes  milk 
that  gradually  becomes  normal  in  quality  and  quantity,  depending  on 
her  general  condition.  It  is  usual  for  an  infant  to  lose  some  weight 
during  its  first  week  of  life,  owing  to  various  physiological  changes, 
added  to  which  is,  no  doubt,  the  deficiency  in  the  quality  and  quantity  of 
its  food.  It  is  a  safe  plan,  and  one  that  I  have  always  urged,  if  at  all  pos- 
sible, to  send  a  specimen  of  breast-milk  to  a  chemist  and  submit  the  same  to 
a  chemical  analysis.  In  some  women  a  specimen  can  be  examined  when  the 
baby  is  one  week  old;  in  others  it  is  better  to  wait  until  the  end  of  two 
weeks.  We  then  would  have  a  proper  working  basis,  and  know  just  how 
much  fat,  carbohydrate  (sugar),  and  albuminoids — including  proteids — we 
are  feeding.  Noting  the  weight  of  the  child,  its  sleep,  its  digestion,  color 
and  frequency  of  its  stools,  we  can  easily  see  in  one  week  how  much  the  infant 
has  gained  in  weight,  and  its  general  condition.  To  take  a  specimen,  it  is 
advisable  to  have  all  utensils  absolutely  clean;  hence  the  following  plan 
would  be  suggested :  Boil  an  ordinary  one  or  two-ounce  bottle  in  water,  to 
which  a  pinch  of  baking  soda  has  been  added,  for  about  one-half  hour.  Then 
place  the  bottle  in  plain  water  and  boil  again  for  a  half-hour.  Then  turn 
the  bottle  upside  down,  and  allow  it  to  drain  and  dry.  In  this  manner  we 
can  completely  sterilize  the  inside  of  the  bottle  and  avoid  contamination. 

Withdraw  a  sample  of  breast-milk  by  means  of  a  breast-pump.  One 
which  has  served  the  author  very  well  is  known  as  the  Florence  breast-pump, 
and  has  a  glass  mouth-piece.  (See  Fig.  35.)  Another  form  is  an  English 
l)reast-pump,  having  a  rubber  bulb.  Compressing  this  bulb,  we  can  suck 
about  an  ounce  or  more  in  from  five  to  ten  minutes.  This  milk  is  to  l)e 
poured  into  the  bottle,   and  well  corked,   and   set   in   a   refrigerator,   but 


Table  No.  11. — Comparative  Analyses  of  Breast-milk. 


Human  Milk. 

Fat. 

Proteids. 

Sugar. 

Ash. 

Authority. 

Normal  Milks. 

Average 

2.90 

3.07 

5.87 

0  16 

A.  W.  Blythe. 

Average 

3.68 
2  67 

1.70 
3  92 

7.11 
4  37 

0.20 
0  14 

Average 

Vernois  &  Becquerel. 

Average 

3.52 

2.01 

5.91 

14  analyses  from  same  woman 

2.53 

3.42 

4  82 

0.23 

Simon. 

Mean  of  6,  aged  23-33  years  . 

3  82 

2.04 

5.93 

0.42 

H.  Gerber. 

Average 

3.55 

1.52 

6.50 

0.45 

Chevalier  &  Henry. 

From  woman  aged  18 

3.20 

2.39 

6.83 

0.29 

J.  Bell. 

From  woman  aged  33 

2.99 

2.51 

6.51 

0.30 

J.  Bell. 

4  days  after  delivery 

4  30 

3.53 

4.11 

0.21 

Clemra. 

9  days  after  delivery 

3.53 

3.69 

4.30 

0.17 

Clemm 

12  days  after  delivery 

3.31 

2.91 

3.15 

0.19 

Clemm. 

Average  of  84  samples   .... 

4.13 

2.00 

(!.9I 

0.20 

Leeds. 

Average  of  107  samples  .... 

3.78 

2.09 

6.21 

0.31 

Konig. 

68 


INFANT  FEEDING. 


not  on  the  ice.  Milk  will  keep  for  many  hours  in  this  way.  My  plan  has 
been  to  inform  the  chemist  the  clay  previous  to  submitting  the  sample,  so 
that  it  can  be  withdrawn  from  the  breast  early  in  the  morning — at  about 
8  A.M. — and  sent  to  the  laboratory  at  once.  The  result  of  the  analysis  can 
be  received  on  the  evening  of  the  same  day  or  on  the  following  day  in  all 
instances.  A  point  worth  noting  is  that  the  very  first  milk — known  as  the 
foremilk — should  not  be  used,  but  the  infant  should  be  allowed  to  suck  at 
the  breast  for  about  two  minutes  before  pumping  the  sample.  After  this 
the  breast-pump  should  be  applied  for  five  minutes  to  procure  the  so-called 
middle  milk  for  examination;  then  the  infant  can  again  be  put  to  the 
breast  to  finish  the  so-called  end  of  nursing  or  to  suck  the  strippings. 


FijC.  26. — Specimen  of  Breast- 
milk  from  a  Young  Mother,  17  years 
old.  I'rimipaj-a.  Baby  four  months 
old;  thriving;  gaining  in  weight; 
stools  yellow;  sleeps  well.  Chemical 
examination:  Fat,  2. GO;  sugar,  6.50; 
proteids,  2.54.  ililk  looks  creamy, 
and  the  mammae  are  well  filled. 

(Original.) 


Fig.  27. — Specimen  of  Breast- 
milk,  Illustrating  Very  High  Fat, 
Causing  Gastric  Disturbance.  Baby 
gaining;  vomits  frequently;  stools 
yellowish;  bluish  white  milk;  child 
sleeps  well;  excessive  fats.  Chem- 
ical analysis:  Fat,  5.0;  sugar,  6.50; 
proteids,  1.74;    ash,  0.20.     (Original.) 


Examination  of  Breast-milk. — A  method  which  can  be  employed  in 
general  practice  is  recommended  by  Friedmann  (Deut.  med.  Woch.,  Jan. 
23,  1902).  It  is  more  easily  done  than  a  chemical  analysis,  and  serves 
an  equal  purpose.  It  consists  of  determining  by  microscopical  examination 
the  number  and  character  of  the  milk  corpuscles.  It  is  an  advantage  first 
to  become  familiar  with  the  normal  conditions  by  repeated  examinations 
of  the  milk  from  healthy  mothers,  those  whose  children  are  well  and  show 
no  signs  of  rickets  or  glandular  enlargements.  The  milk  corpuscles  can 
be  divided  as  to  size  into  three  groups,  large,  small,  and  intermediate,  of 
which  the  latter  are  most  numerous.     The  small  ones  are  also  found  in 


WOMAN'S  MILK.  69 

almost  equal  numbers,  but  the  large  ones  are  comparatively  scarce,  a  mag- 
nification of  400  diameters  showing  only  about  10-20  in  the  field.  If  these 
be  more  numerous  the  milk  is  found  to  be  too  fatty  and  more  difficult  to 
digest.  A  preponderance  of  the  small  corpuscles  usually  means  a  chronic 
dyspepsia  for  the  nursing  infant.  An  accurate  count  can  be  made  with 
some  form  of  blood-counting  apparatus,  but  the  latter  is  not  essential.  The 
proximity  of  the  corpuscles  to  each  other  also  serves  as  a  guide  to  the  grade 
of  the  milk,  the  more  sparsely  distributed  the  globules  and  the  greater  the 
number  of  the  small  ones,  the  poorer  the  quality  of  the  milk.  The  method 
also  serves  to  differentiate  the  character  of  the  milk  from  the  two  breasts. 
In  the  selection  of  wet-nurses  it  is  obviously  useful. 

Reaction  of  Human  Milk. — Bordet  has  called  attention  to  the  precipi- 
tation of  the  alI)uminoids  in  milk  when  it  is  added  to  the  serum  in  anima's 
which  have  been  previously  injected  with  milk  from  the  same  source. 
.Schlossmann  found,  further,  that  the  fluid  from  a  hydrocele  on  a  breast 
child  was  also  able  to  precipitate  the  alliuminoids  in  luiinan,  l)ut  not  in  cows' 
milk.  ]\Ioro  now  announces  that  if  a  few  drops  of  human  milk  are  added 
to  a  few  cubic  centimeters  of  fluid  from  a  hydrocele,  in  a  few  minutes  the 
hydrocele  fluid  coagidatcs  into  a  solid  mass.  This  reaction  does  not  occur 
with  cows'  or  goats'  milk.  The  hydrocele  fluid  evidently  contains  fibrinogen, 
and  the  milk,  fibrin  ferment.  The  combination  of  the  two  induces  the 
coagulation.  It  occurs  even  with  minute  quantities  of  the  milk:  all  the 
serum  in  contact  with  the  milk  coagulates  around  it.'  The  same  reaction 
occurs  when  human  :-erum  is  added  instead  of  the  milk,  but  much  less  pro- 
nounced and  much  slower,  and  the  same  difference  is  observed  when  the 
human  milk  is  boiled  or  long  heated.  Particles  of  coagulated  ox  blood  also 
induced  a  slow  and  ])artial  coagulation. 

Diastatic  Enzyme  in  Human  Milk  and  in  the  Stools  of  Nursling. — 
Dr.  Ernest  iMoro  reports  from  Eschericirs  clinic,  in  Graz,  that: — 

First. — Human  milk  contains,  normally,  an  intensive,  saccharifying 
enzyme,  which  is  not  found  in  cows'  milk. 

t-^ecoiid. — This  cnzyiiic  is  found  in  the  stool  of  ])reast-fed  children  and 
signifies  a  more  pronounced  diastatic  action  of  the  same. 

Third. — This  diastatic  enzyme  is  secreted  l)y  the  glands  of  the  intestine. 
Parts  of  the  same  can  be   found   in   the  ])a!icreatic  juice  of  the  new-born. 

Foiirtlt. — The  intestinal  contents  and  fjieces  of  nurslings  contain  at 
birth,  as  a  rule,  a  diastatic  enzyme,  wliich  increases  in  the  first  few  weeks  of 
life. 

Immunity  Conferred  by  Breast-milk. — The  nuising  infant  is  usually 
(•xcnipt  from  infectious  diseases,  altlmuuli  we  do  (ind  an  occasional  case  of 
infection  in  a  bresist-fed  infani.      Such  is  the  e\e(»plion  ratlier  than  the  rule. 

]»ead  chapter  on  '"M(>asles"  for  cases  of  inimunity  seen  by  me  in  the 
Hiverside  Hospital. 


70 


INFAiNT  FEEDING. 


There  seems  to  be  an  iininunity  conveyed  to  the  infant  through  its 
mother's  milk.  These  substances  which  convey  immunity  have  been 
studied  by  Brieger  and  Ehriich.  During  epidemics  nursing  infants  rarely 
succumb  to  infections.  The  folloM'ing  case  will  illustrate  the  manner  in 
which  innnunity  can  be  "conveyed"  through  the  milk: — 

A  woman  suffering  with  dii)lithoiia  was  four  months  pregnant  at  the  time  of 
infection.  She  was  injected  with  2000  units  of  antitoxin  and  recovered  in  about 
six  days.  Several  months  after  the  birtli  of  her  child,  an  older  child  in  the  family 
was  attacked  with  diphtheria,  which  required  several  injections  of  antitoxin,  also 
intubation,  to  relieve  a  severe  form  of  croup.  Although  the  new-born  infant  was 
in  the  same  room  it  did  not  show  any  signs  of  the  disease.  Tliis  was  most  likely  due 
to  the  immunity  conferred  upon  the  child  by  its  mother  through  her  breast-milk. 

To  Preserve  Human  Milk.— Human  milk  collected  from  various 
women  may  be  preserved  for  many  weeks  if  treated  in  the  following 
manner:  Test  the  milk  with  litmus  paper  to  be  sure  that  it  is  ampho- 
teric or  alkaline.  If  it  is  not  alkaline,  add  a  few  drops  of  bi-carbonate 
of  soda  solution.  Then  add  0.2  cubic  centimeters  of  a  concentrated  30 
])er  cent,  perhydrol  solution.  This  quantity  of  perhydrol  is  sulficient 
for  400  cubic  centimeters  milk.  The  milk  is  then  thoroughly  shaken  so 
that  the  perhydrol  produces  its  chemical  effect.  On  close  inspection 
sHuiU  bubbles  can  be  seen  in  the  milk.  Lastly  the  milk  is  heated  for  ten 
minutes  in  a  water  bath  to  120  degrees  F.  ]\[ilk  so  treated  by  Dr. 
Meierhoffer  was  tasted  by  me  in  the  Children's  Wards  of  Dr.  Paul  Moser, 
in  Vienna,  and  seemed  perfectly  fresh  although  it  was  one  month  old. 

Takle  Xo.  12. — Five  Analyses  of  Human  Breast-Diilk.^ 


Case 

No.  1. 

Per  cent. 

Case 

No.  2. 

Per  cent. 

Case 

No  3. 

Per  cent. 

Case 

No.  4. 

Per  cent. 

Case 

No.  5. 

Per  cent. 

Water     

86.2 
1.7 
6.5 
5.4 
0.2 

89.0 
1.3 
5.8 
2.5 
0.3 

87.0 
1.6 
6.6 
3.8 
0.2 

88.6 
1.1 
6.7 
2.7 

88.1 

1.1 

Lactose  

Fab 

Salts 

6.2 
4.1 

Case  I  of  Table  12  showed  symptoms  of  gastric  distui-bance,  chiefly 
vomiting,  caused  by  "feeding  high  fat."  The  mother  of  the  infant  believed 
that  by  eating  frequently  and  of  very  rich  food,  she  would  benefit  her  baby, 
thus  her  milk  showed  5.4  per  cent,  of  fat. 

By  reducing  her  diet,  excluding  meat  and  too  many  eggs,  discontinuing 
alcoholic  and  malted  beverages,  her  milk  im])roved,  the  fat  being  decreased. 
Exercise,  sucli  as  walking,  was  or(lci'<'d  for  the  mother. 


^  Analyses  made  by  Lafayette  B.  ^Mejidcl,  Yale  University,  New  Haven,  Connec- 


ticut. 


BREAST-FEEDING. 


71 


Table  No.  13. — Table  Showing  Analyses  of  a  Normal,  a  Poor, 
an  Over-rich,  and  a  Bad  Human  Breast-milk  i 


Fat 

Sugar  

Proteids 

Mineral  Matter  . 

Total  Solids  .  .  . 
Water 

Total  .... 


Normal  Milk. 
Exercise  and 
Good  Food. 


4.00 

6.50 

1.75 

.19 

12.44 

87.56 

100.00 


Poor  Milk. 

Poor  Food. 

(Low  Fat. 

High  Proteids  ) 


1.00 

6  50 

2.36 

.24 

10.10 
89.90 

100.00 


Over-rich  Milk. 
Rich   Food, 
No  Exercise. 

(Excess  of  Fat. ) 


6.59 

6.69 

1.16 

.19 

14.63 
85.37 

100.00 


Bad  Milk. 

Wet-nurse 
Menstruating. 

(Low  Fat. 
Low  Proteids.) 


.65 
6.. 50 
1.12 

.11 

8.38 
91.62 

100.00 


Specimens  examined  by  Mr.  Bailey,  chemist  of  the  Pediatrics  Laboratory. 

Breast-feeding. 

During  the  first  montli  feed  every  two  liours,  but  never  oftener.  Dur- 
ing the  second  month  ever}^  two  and  a  lialf  to  three  hours. 

During  the  day  disturb  the  child  every  two  hours,  to  be  nursed;  but 
during  the  night  leave  the  child  rest  as  long  as  it  appears  satisfied.  This 
rule  applies  to  healthy  children  ouly.  In  sickness  special  rules  for  feeding 
are  required.  If  the  child  thrives  and  gains  in  weight,  then  it  is  advisable 
and  in  the  interest  of  the  mother  and  child  to  have  an  interval  of  from  seven 
to  eight  hours  at  night;  thus  Bouchut  advises  feeding  between  10  and  11 
at  night,  and  commencing  the  morning  meal  at  6  a.m.  If  the  child  is  rest- 
less, then  turn  it  from  side  to  side;  in  other  words,  changing  its  position  and 
giving  it  one  or  two  teaspoonfuls  of  boiled  water  will  frequently  satisfy  it 
and  prolong  its  sleep. 

Table  No.  14.— Tme  for  Feeding. 


From  Birth 

Until  1  .Month 

Old. 

From  1  to  2 
Months  Old. 

From  2  to  4 
Months  Old. 

From  4  to  6 
Months  Old. 

From  6  to  9 
Months  Old. 

From  9 

Months  Until 

1  Year  Old. 

6  A.  M. 

6  A.  M. 

6  A.  M. 

6  A.  M. 

6       A.  M. 

6  A.  M. 

8  A.  M. 

8  A.  M. 

8.30  A.  M. 

9  A.  M. 

9.30  A.  M. 

10  A.  M. 

10  A   M. 

10  A.  M. 

11        A.  M. 

12  Noon 

1        P.  M. 

2  P.  M. 

12  Noon 

12  Noon 

1.30  P.  M. 

3  P.  M. 

4.30  P.  M. 

6  P.  M. 

2  P.  M. 

2  P.  M. 

4        P.  M. 

6  P.  M. 

8       P.  M. 

10  P.  M. 

4  P.  M. 

4  P.  iVT. 

6.30  P.  M. 

9  P.  M. 

12       Mid- 

6 P.  M. 

6  P.  M. 

9       P.  M. 

12  INIid- 

night 

8  P.  M. 

8  P.  M. 

12       Mid- 

night 

10  P.  M. 

12  Mid- 

night 

12    Mid- 

night 

ni^rlit 

3  A.  M. 

2  A.  M. 

*  I  am  indebted  to  the  chemist  of  the  Walker-Gordon  Laboratory  for  a  series  of 
chemical  analyses  herein  reported. 


72  INFANT  FEEDING. 

The  first  three  or  four  days  require  special  feeding  methods.  On  the 
day  of  the  birth,  the  exhaustion  of  the  mother  and  presence  of  colostrum, 
besides  the  normal  deficient  quantity  of  food  in  the  breast,  demand  large 
intervals  of  rest.  Thus  for  the  first  three  days  (unless  the  milk-supply  is 
profuse)  putting  the  infant  to  the  breast  once  in  six  hours  is  sufficient;  if, 
however,  the  supply  of  milk  is  ample,  then  we  can  follow  the  table  given 
above  and  nurse  the  infant  every  two  hours. 

Suggestions  for  Breast-feeding. 

The  mother  or  wet-nurse  should  always  sit  upright,  be  it  at  night  or 
during  the  day,  while  nursing  the  infant. 

Danger  of  Suffocation. — A  great  many  cases  are  on  record  where  the 
mother  or  wet-nurse  has  fallen  asleep  while  nursing  and  smothered  the  in- 
fant. For  this  reason  it  is  important  that  the  infant  should  sleep  in  its 
own  crib  or  bed,  and  should  never  sleep  with  the  mother  or  nurse. 

Shall  an  Infant  Receive  but  One  or  Both  Breasts  for  One  Meal? — 
This  depends  on  the  infant's  appetite.  Some  infants  appear  satisfied 
after  nursing  from  one  breast,  and  will  let  go  of  the  nipple  and  fall  asleep. 
Lightly  tapping  the  cheeks  of  the  infant  will  awaken  it,  or  the  withdrawal 
of  the  nipple  from  the  infant's  mouth  will  frequently  arouse  it  to  continue 
nursing.  If,  however,  the  infant  will  not  renew  its  nursing,  and  still  con- 
tinues to  sleep,  and  if  the  infant  has  nursed  steadily  for  ten  minutes,  then 
the  sleep  should  not  be  disturbed. 

Length  of  Time  for  Nursing. — A  good  plan  is  to  note  the  time  when 
the  nursing  act  commences  and  stops.  No  infant  should  nurse  longer  than 
twenty  minutes,  whereas  frequently  ten  or  fifteen  minutes  will  suffice.  If 
an  infant  nurses  more  than  twenty  minutes,  say  thirty  or  forty  minutes, 
then  we  may  be  sure  that  the  breast-milk  is  deficient  in  quantity  and  a 
specimen  should  at  once  be  submitted  for  a  proper  chemical  examination. 

Scanty  Breast-milk  Eequiring  Mixed  Feeding. 

When  there  is  a  deficiency  in  the  quantity  of  breast-milk,  but  the  quality 
is  good,  then  it  is  advisable  to  feed  the  infant  alternately  with  breast-milk 
and  bottle-milk.  At  the  same  time  it  is  advisable  to  direct  attention  to  the 
mother's  general  condition,  and  see  if  we  cannot  tone  her  up,  and  thus  im- 
prove both  quality  and  quantity  of  her  milk.  Frequently  a  subnormal  or  an 
anaemic  condition  requires  iron.  A  day's  outing  to  the  country  or  seashore, 
with  moderate  exercise,  will  stimulate  and  increase  the  flow  of  milk.  Every 
drop  of  breast-milk  is  so  precious  that  no  infant  should  be  deprived  of  it, 
and  wise  is  the  physician  who  will  insist  upon  giving  all  breast-milk.  When 
there  is  deficient  lactation,  supply  the  deficiency  by  giving  a  properly  diluted 
milk  or  cream  mixture,  adapted  for  the  age  and  weight  of  the  infant. 


DISTURBANCES  DURING  BREAST-FEEDING.  73 

To  Increase  the  Quantity  of  Breast-milk. — Some  of  the  galactagogues 
have  given  me  satisfaction,  in  addition  to  a  nutritious  diet,  such  as  meat, 
milk,  and  eggs.  A  preparation  on  the  market  known  as  Nutrolactis^  has 
proven  a  most  valuable  galactagogue.  It  is  given  in  tablespoonful  doses 
three  times  a  day.  This  will  not  only  stimulate  the  quantity  but  also  the 
quality  of  the  milk.  Grand  in  and  Jarman,  in  their  text-book  on  *'Obstet- 
rics,''  recommend  the  strong  infusion  of  galega  officinalis  when  the  flow  of 
milk  is  scant.  This  is  to  be  ordered  in  tablespoonful  doses  three  or  four 
times  a  day. 

Somatose  in  Cases  of  Deficieiit  Lactation. — "A  primipara  who  secreted  only  a 
limited  amount  of  colostrum,  and  kept  that  up  so  that  the  child  was  crying  from 
hunger  and  had  to  be  artificially  fed  was  put  upon  somatose,  4  teaspoonfuls  a  day, 
and  in  three  days  the  patient  secreted  a  sufficient  quanity  and  quality  of  milk  to 
satisfy  the  child,  which  increased  one-fourth  of  a  pound  regularly  each  week.  It 
seemed  difficult  to  induce  the  mammary  glands  to  perform  their  proper  function; 
but  when  somatose  was  given  there  was  a  normal  supply  of  milk,  and  the  child  was 
properly  nourished  without  artificial  feeding." 

Do  Drugs  Taken  by  a  Nursing  Woman  Affect  the  Baby? 

Physiological  experiments  have  frequently  demonstrated  the  fact  that 
a  great  many  drugs  can  be  given  to  an  infant  through  the  milk ;  thus,  opium 
and  morphine  and  narcotics  in  general  do  affect  the  infant,  when  taken  by 
the  mother.  Baginsky  calls  attention  to  this  fact  in  his  text-book  on  "Dis- 
eases of  Children":  "Alcohol,  when  taken  by  the  mother,  is  transmitted 
through  the  milk,  but  not  in  very  large  quantities.  The  following  is  a  list 
of  drugs  which  have  been  found  in  milk :  The  purgative  principles  of  rhu- 
barb, senna,  and  castor-oil;  the  metals,  antimony,  arsenic,  iodine,  bismuth, 
lead,  iron,  mercury;  the  volatile  oils,  like  copaiba,  garlic,  and  turpentine; 
also  salicylic  acid,  and  the  iodides  and  bromides."  Do  not  give  cocaine, 
chloral,  atropine,  or  hyoscyamus.  Care  is  to  be  used  with  the  following: 
Digitalis,  antipyrio,  and  ergot.  An  unpleasant  flavor  can  be  imparted  to 
the  breast-milk  by  the  mother  or  wet-nurse  eating  onions,  turnips,  cauli- 
flower, or  cabbage. 

Disturbances  During  Breast-feeding. 

Quite  frequently  we  meet  with  gastro-intestinal  disorders  in  infants 
that  are  wholly  breast-fed.  These  disturbances  are  due  to  (a)  insufficient 
exercise;  (h)  faulty  diet;  (c)  extreme  nervous  irritability;  (d)  menstrua- 
ation  while  nursing;  (e)  physiological  changes  in  the  woman  causing  an 
improper  ratio  of  ingredients.  Some  of  the  causes  just  mentioned  can  easily 
be  remedied.  On  the  other  hand  a  very  nervous  woman  wliose  anxiety  keeps 
her  constantly  fretting  during  the  day  and  awake  at  night,  will  hardly  be 

'Sold  in  all  drug  stores. 


74  INFANT  FEEDING. 

adapted  for  breast-feeding,  and  the  sooner  the  infant  is  removed  from  such 
a  breast,  the  better  for  the  infant. 

The  following  cases  will  illustrate  the  above  conditions: — 
An  infant  was  nursed  by  its  mother.     The  mother  was  extremely   nervous, 
fretful,  did  not  sleep  at  night,  and  nursed  her  child  too  often. 

The  infant  suffered  with  colic,  had  greenish,  cheesy  stools,  and  did  not  gain  in 
weight.  Had  indigestion  and  all  evidences  of  intestinal  colic.  The  ease  was  seen 
by  me  through  the  courtesy  of  Dr.  A.  A.  Richardson,  of  New  York  City.  The  physician 
assured  me  that  the  mother  would  not  leave  her  home,  and  that  she  had  had  no  out- 
door exercise,  no  fresh  air,  and  nothing  but  the  constant  worry  of  a  sick,  crying 
baby  which  she  nursed  as  best  she  could.  A  chemical  examination  of  the  breast- 
milk  showed  the  following: — 

Fat    1.20 

Sugar 6.50 

Proteids   1.70 

Ash    13 

Total  solids 9.58 

Under  the  influence  of  exercise  and  careful  diet  the  fat  was  increased.  In  this 
case  we  alternated  breast  and  bottle  feeding,  and  gave  the  child  mixed  feeding.  A 
formula  of  2  per  cent,  fat,  5  per  cent,  sugar,  and  0.75  per  cent,  proteids,  was  pre- 
scribed at  the  Walker-Gordon  Laboratory. 

An  infant  one  month  old  was  seen  by  me  in  the  family  of  Dr.  J.  Grosner,  of 
this  city.  The  infant  had  been  vomiting,  had  had  colic,  and  was  very  restless.  The 
mother  was  veiy  nervous,  but  had  an  abundance  of  milk.  From  the  history  I 
learned  that  the  child  had  an  explosive  vomit;  the  food  coming  out  besides  large 
quantities  of  gas.  There  were  five  to  seven  stools  in  twenty-four  hours.  The  bowels 
moved  at  each  nursing.     The  chemical  examination  of  the  breast-milk  showed: — 

Fat 4.00 

Sugar    6.50 

Proteids    3.05 

Ash    30 

Total  solids 13.85 

From  this  examination  it  can  be  seen  that  for  a  baby  six  months  old 
there  was  an  excess  of  fat  and  also  a  very  high  percentage  of  proteids. 

An  infant  one  to  two  months  old  requires  2  per  cent,  of  fat.  Note  also 
a  normal  infant  receives  between  1  and  1  ^/o  per  cent,  of  proteids,  while  this 
child  received  more  than  3  per  cent,  of  ])roteid^:.  There  being  a  profuse 
secretion  of  milk,  llio  child  received  far  more  tliau  it  could  digest  in  both 
quality  and  quantity.  The  feeding  interval  was  lengthened,  and  the  time 
of  nursing  was  reduced  to  five  minutes,  whereas  until  the  appearance  of 
vomiting  the  child  nursed  twenty  minutes.  An  ounce  of  sterilized  water  was 
ordered  immediately  after  each  nursing,  hoping  to  thus  dilute  the  milk. 
This  method  proved  successful. 


BREAST-MILK- 


75 


A  Case  of  Prolonged  Lactation,  Showing  Deflciency  of  Nutriment. — A  child, 
about  one  year  old,  was  brought  to  me  with  the  following  histoi-y :  It  has  no  teeth. 
Can  neither  stand  nor  walk.    It  is  colicky.     Does  not  sleep  well.     Does  not  gain 


Fig.  28. — Showing  a  Drop  of  Milk  under  the  Microscope.  Note  the 
poor  character  of  this  emulsion,  the  uneven  fat-globules,  and  their  irregular 
size  and  distribution.  The  infant  nursed  with  the  above  milk  was  rachitic 
and  colicky.  Although  15  months  old,  no  tooth  had  appeared.  The  mother 
of  the  infant  states  that  she  menstruated  every  twenty-one  or  twenty-two 
days  since  her  infant  was  born — during  this  present  nursing  period. 
(Original.) 


Fig.  29. — This  Drop  of  Breast-milk  is  from  a  very  Anaemic  Woman. 
The  child  was  extremely  emaciated;  had  greenish  stools,  and  colic,  and  was 
always  crying.  Note  the  uneven  character  of  above  emulsion,  when  com- 
pared with  Plate  IV.  The  infant  was  poorly  nourished;  had  rickets  and 
marked  cranio-tabes.  Mixed  feeding  was  resorted  to,  with  decided  improve- 
ment.     (Original.) 

weight.  The  child  was  nursed  every  three  or  four  hours.  The  mother  was  very 
nervous,  and  menstruated  almost  every  month  during  lactation.  The  chemical  analysis 
of  the  milk  gave: — 

Fat    1.22 

Sugar    7.07 

Proteida   98 


76 


INFANT  FEEDING. 


It  was  very  evident  that  this  babj'  was  receiving  poor  milk,  very  low  fat,  and 
deficient  proteids.  The  infant  was  weaned,  artificial  feeding  was  prescribed,  and  the 
infant  immediately  showed  a  gain  in  weight.     The  symptoms  of  colic  disappeared. 

Illustration  of  Prolonged  Lactation  Without  Apparent  Harmful  Effects. — An 
infant  fifteen  months  old  was  brought  to  me  for  the  relief  of  constipation.  It  had 
ten  teeth,  was  able  to  stand  and  walk,  and  was  beginning  to  talk.  The  infant  was 
still  breast-fed.    The  analysis  of  the  milk  gave  the  following: — 

Fat 2.86 

Sugar    G.78 

Proteids  1.7G 


Fig.  30.— Holt's  Milk  Test  Set,  for  Testing  Human  Milk. 

The  infant's  weight  in  this  case  was  normal,  and  I  must  regard  this 
prolonged  lactation,  showing  such  good  result,  as  an  exception  rather  than 
a  rule. 

Additional  Foods  During  the  Nursino  Period. 

When  a  nursing  infant  is  six  to  nine  months  old,  certain  additional 
foods  can  be  given ;  thus,  for  example,  the  white  of  a  raw  egg  can  be  given 
every  second  day,  and  on  the  alternate  day  several  ounces  of  a  meat  soup 
(beef  or  chicken)  in  which  barley,  farina,  or  sago  has  been  boiled  and 
strained.  This  method  of  feeding  can  be  kept  up  until  the  child  is  about 
1  year  old.  A  small  piece  of  zwieback  or  rusk  can  be  allowed  every  day. 
As  this  is  hard  children  like  to  nibble  on  it.    It  seems  to  soothe  their  gums. 


FLOUR-BALL  FEEDING.  77 

Flour-hall  Feeding. — This  is  highly  recommended  by  Dr.  Edwin  Rosen- 
thal.^ He  sa3's:  "1  use  the  following  formula,  and  I  can  claim  as  good 
results  therefrom  as  from  any  form  of  home  modification.  It  is  known  as 
the  flour-ball  food,  commercially  imperial  granum.  It  is  made  as  fol- 
lows : — 

"Plain  wheat-flour  is  boiled  in  a  bag  for  five  hours;  it  is  then  baked 
in  an  oven  until  perfectly  hard  and  dry.  After  cooling  it  is  broken  open, 
the  rind  rejected,  and  grated  into  a  powder.  For  a  child  one  month  old 
I  order: — 

Scalded   milk    •» ^/a  pint 

Sterile  water   1     pint 

Grated  flour-ball  1  heaping  tablespoon 

"The  milk  is  placed  on  the  fire  and  heated;  the  flour  is  rubbed  into  a 
paste  with  the  water  and  added  to  the  milk.  This  is  brought  to  the  boiling 
point,  taken  from  the  fire,  set  aside  to  cool,  and  then  placed  on  the  ice. 
Finally  add  enough  raw  milk  to  make  two  pints  in  all.  At  feeding  time  the 
required  amount  is  heated  to  feeding  temperature. 

"For  a  child  one  month  old,  two  ounces  is  given  every  two  hours.  It  is 
increased  a  half-ounce  every  month." 

I  advise  using  the  following  formula  for  a  child  six  months  old : — 

Flour-ball    1  teaspoonful 

Rice  water 4  ounces 

Raw  milk  (certified  or  guaranteed) 4  ounces 

Granulated  sugar   1  teaspoonful 

Rub  up  the  flour-ball  with  a  little  rice  water,  and  gradually  add  the 
full  quantity.  Add  the  sugar,  and  lastly  the  raw  milk.  Heat  to  a  tem- 
perature of  150°  F.  for  two  or  three  minutes. 

One  bottle  containing  the  above  can  be  given  instead  of  a  breast-feeding, 
or  if  the  milk  is  scanty  we  can  alternate  a  breast-feeding  with  a  bottle- 
feeding  of  the  above  formula.  If  this  feeding  agrees,  but  the  child  appears 
hungry  after  the  bottle,  the  milk  may  be  increased  and  the  rice  water  de- 
creased gradually,  one  ounce  at  a  time,  until  full  milk  is  given.  The  guide 
for  increasing  the  food  should  be  a  yellowish  pasty  condition  of  the  stool, 
the  increase  in  weight,  and  the  absence  of  colic. 

The  Diet  of  a  Nursing  Mother. 

Immediately  after  the  birth  of  the  child  the  exhausted  condition  of  a 
woman  following  labor  will  certainly  call  for  rest;  hence  sleep  is  imperative, 
after  which  some  form  of  stimulation  is  required.    This  can  best  be  accom- 


*  Paper  read  before  the  Pennsylvania  State  Society,  May  18,  1898,  entitled  "Some 
Points  on  Infant  Feeding." 


78  INFANT    FEEDING. 

plished  by  giving  at  intervals  of  several  hours  good  wholesome  food,  as 
chicken  broth  or  Jjcef  broth,  weak  tea,  or  strained  gruel.  It  is  unnecessary 
to  state  that  each  woman's  case  and  her  former  habits  must  l)e  taken  into 
consideration  in  prescribing  a  diet.  If  labor  has  Ijeen  n<^>rii'al,  then  the  nour- 
ishment will  stimulate  the  milk.  If  warm  liquids  are  not  well  borne,  then 
cold  drinks  like  buttermilk,  koumyss,  zoolak,  or  iced  tea  should  be  em- 
ployed. Iced  champagne  will  frequently  do  more  good  to  allay  gastric  irrita- 
l)ility  than  all  medication.  JJaw  milk  in  combinati(ni  witli  seltzer  or  lime- 
water  is  indicated.  In  some  instances  ice-cream  will  aid  nutrition  and  alle- 
viate gastric  irritation.  If  the  pelvic  condition  is  normal,  then  it  is  wise 
not  to  give  solid  food  for  the  first  three  days,  but  rather,  stimulate  the  milk- 
glands  by  giving  meat  broths,  farinaceous  gruels,  and  by  all  means  milk. 
Zwieback  soaked  in  milk. or  in  tea  is  highly  nutritious  and  easily  digested. 
Other  nutritious  foods  are  calfsfoot  jelly  and  chicken  jelly. 

After  the  third  day,  if  the  pelvic  organs  are  normal,  it  is  wise  to  con- 
sider the  action  of  the  bowels.  If  the  bowels  have  not  moved  by  this  time, 
then  buttermilk  added  to  the  diet  or  stewed  prunes  or  peaches,  baked  apples 
or  grapes,  will  aid  in  establishing  a  movement  of  the  bowels. 

If  the  milk  is  scanty  and  the  bowels  have  not  moved,  then  the  best 
remedy  is  a  large  tablespoonful  of  palatable  castor-oil,  modified  to  suit 
the  taste  by  the  addition  either  of  lemon  juice  or  orange  juice,  or  by  adding 
several  drops  of  the  ordinary  spirits  of  peppermint.  After  the  bowels  have 
been  evacuated  and  the  general  condition  warrants  it,  then  a  diet  consisting 
of  the  following  is  indicated : — 

BREAKFAST,   7   TO   8   A.M. 

Hominy  and  Milk.  Grapes. 

Farina  and  Milk.  Soft-boiled  Eggs. 

Rice  and  Milk.  Poached  Eggs. 

Oatmeal  and  Milk.  Eggs  on  Toast. 

Germea  and  Milk.  Coffee  and  Milk. 

Cream  of  Wheat  and  Milk.  Tea  and  Milk. 
Some  Stewed  Prunes,  Figs,  or     Cocoa  and  Milk. 

Peaches.  Toast    and  Butter, 

Stewed  Apples.  Stale  Bread  (2  days  old),  with 

Oranges.  Butter. 

I  do  not  advise  meat  or  fish  in  the  morning,  unless  the  nursing  mother 
has  always  been  accustomed  to  this  form  of  diet. 

LUNCH,  12  TO  1  P.M. 
Some  soup  made  from  meat,  either  veal,  beef,  mutton,  lamb,  or  chicken, 
containing  also  some  rice,  barley,  farina,  sago,  or  hominy;   it  should  not 
be  highly  seasoned,  and  should  not  be  strained. 


DIET  OF  A  NURSING  MOTHER.  70 

Fish,  boiled  or  fried,  and  all  shell-iish,  particularly  oysters,  are  very 
nutritious  during  the  nursing  period. 

If  the  appetite  warrants  it,  then  a  piece  of  steak  or  chop,  roast  beef, 
chicken  (white  meat  only),  or  raw  choijped  meat,  with  bread  and  butter, 
is  very  nutritious. 

EVENING^  6  TO   7  P.M. 

A   Bowl  of  Oatmeal  Gruel.  Junket. 

Stewed  Oysters.  Cup  of  Tea. 

A  Drink  of  Milk.  Eggs,  if  desired. 

Farina  Pudding.  JMeat,  if  in  the  habit  of  eating 

Eice  Pudding.  it  in  the  eveuing. 

Cornstarch  Pudding. 

For  Thirst. — Cool,  filtered  water,  or  the  alkaline  waters,  like  Se'tzer 
and  Apollinaris. 

If  the  milk  is  scanty,  the  flow  can  he  stimulated  by  drinhing  a  cup  of 
hot  broth,  made  from  beef,  chicken  or  veal,  lamb  or  mutton,  several  minutes 
before  putting  the  child  to  the  breast. 

Alcoholic  Drinks. — If  the  woman  is  in  the  habit  of  drinking  wine  or 
beer,  then  it  is  unwise  to  discontinue  the  use  of  alcoholics  in  moderate 
quantities  while  she  is  nursing.  I  have  seen  a  great  many  women,  whose 
flow  of  milk  was  scant,  who  immediately  secreted  an  abundance  of  milk 
after  partaking  of  a  glass  of  beer  or  ale  or  porter  with  their  meals  for  sev- 
eral days.  Beer  has  a  decided  laxative  effect,  and  this  in  itself  is  rather  an 
advantage  for  those  nursing  mothers  having  a  tendency  to  constipation.  So 
my  rule,  therefore,  would  be  to  insist  on  abstinence  from  wine  and  beer 
unless  the  patient  has  been  in  the  habit  of  taking  it  formerly. 

FOODS  TO  BE  AVOIDED  BY  A   NURSING   WOMAN. 

Onions.  Ethereal  Oils. 

Garlic.  Butter  and  Fat  moderately. 

Cabbage.  Candies  and  too  much  Sweets. 

Powerful  Salts  (Rochelle,  Glau-  Large  quantities  of  Potatoes. 
ber,  Epsom). 

Inability  of  Mothers  to  Nurse  their  Children. 

It  is  surprising  to  note  the  gradual  disappearance  of  the  healthy,  robust 
American  mother  who  can  perform  the  duty  of  nursing  her  infant.  The 
following  table  will  give  a  fair  illustration  of  the  conditions  as  they  exist  in 
Kew  York  City  to-day. 


80  INFANT  FEEDING. 

Table  No.  15. — A  study  of  1000  Mothers  and  their  ability  to  nurse. 


Mothers. 

Condition 

of 
Mother. 

Able  to  Nurse 

9  Months  to 

1  Year. 

Able  to  Nurse 
4  Days  to 
2  Months. 

Primiparas. 

Multiparas. 

5001 

Living  in  Tene- 
ment Housea. 

Very  Poor. 

450  2 

50 

210 

290 

500 

Living  in 

Healthy 

Portions  of 

the  Ci£y. 
Prosperous. 

84 

150 

305 

195 

According  to  the  above  statistics  90  per  cent,  of  the  poor  mothers  are 
able  to  nurse  their  children,  while  only  17  per  cent,  of  the  rich  mothers 
are  able  to  perform  the  same  duty. 


Wet-nurse. 

Two  important  points  are  necessary:  First,  the  presence  of  suitable 
milk;   second,  the  absence  of  a  constitutional  taint  or  acute  severe  illness. 

What  to  Examine. — First,  the  breasts  for  the  quantity  of  milk  present. 
The  breast  should  be  gently  but  firmly  held  at  some  distance  from  the  nipple; 
thus  we  can  learn  by  palpation  regarding  the  parenchyma  of  the  glands. 
Also  the  quantity  of  milk  which,  if  expressed  continuously  about  twenty 
to  thirty  seconds,  should  flow  in  several  streams. 

Stagnant  milk  always  shows  sensitiveness  on  pressure.  The  statement 
of  a  wet-nurse  that  her  "milk  is  deficient  in  quantity,"  can  be  determined  by 
subjecting  her  to  careful  observation  for  several  hours.  After  this  time  the 
milk  in  the  breasts  should  be  expressed  and  the  quantity  determined. 

The  ease  with  which  milk  can  be  expressed  by  palpation  is  an  impor- 
tant factor  to  note.  If  the  milk  flows  with  great  difficulty,  and  requires 
considerable  massage  or  pumping,  then  such  a  nurse  is  totally  unfit  to  nurse 
atrophic,  marasmic,  or  prematurely  born  babies. 

Weak  or  marasmic  children  require  a  wet-nurse  having  a  plentiful 
supply  of  milk.  Thus  the  slightest  palpation  while  expressing  must  yield 
a  liberal  flow  of  milk. 


*  Thirty-live  or  7  per  cent,  of  these  mothers  suffered  from  puerperal  disease,  such 
as  septicEemia,  mastitis,  and  kindred  affections,  hence  they  were  ordered  by  their 
physicians  not  to  nurse. 

*  Three  hundred  and  twenty-four  infants  were  put  on  artificial  feeding.  This 
feeding  consisted  of  feeding  at  the  laboratory  and  home  modifications.  One  hundred 
and  fifty-four  of  these  infants  were  supplied  with  wet-nurses,  owing  to  loss  of 
weight,  dyspeptic  conditions,  or  marasmus  during  the  bottle-feeding. 


WET-NUESE.  81 

Xotc  if  the  cxprc^siiiG:  of  milk  causes  pain;  in  the  normal  l)rcast  it 
slioukl  be  painless. 

It  is  not  always  the  quality  of  the  milk,  but  frequently  the  ipiantity, 
that  is  the  cause  of  poor  assimilation  of  a  Avet-nurse's  milk.  In  such  in- 
stances a  chemical  examination  of  the  milk  is  imperative;  by  this  we  can 
learn  exactly  how  much  we  feed  an  infant  in  percentages.  If  necessary, 
we  can  modify  the  milk  (by  proper  wet-nurse  diet)  until  the  required  per- 
centages are  attained. 

The  Child  cf  a  Wet-nurse. — Certain  allowances  must  always  be  made 
for  babies  presented  by  wet-nurses — for  instance,  if  the  hygienic  surround- 
ings of  a  wet-nurse  are  very  poor,  and  in  addition  thereto  her  food  supply 
is  meager,  then  a  general  an<i3mic  appearance  must  be  expected.  On  the 
other  hand,  a  healthy,  rolmst-looking  baby  must  not  bo  regarded  as  the 
criterion  by  which  we  should  judge  the  wet-nurse. 

The  tricks  of  wet-nurses  are  manifold.  Frequently  they  will  procure 
a  healthy-looking  infant  and  pass  it  off  as  their  own,  in  order  that  they  may 
pi'ocure  a  position. 

Another  point  is  that  they  will  frequently  resort  to  stuffing  their  bahies 
by  feeding  a  bottle  in  addition  to  their  breast-milk.  Thus  we  must  judge 
for  ourselves  the  quality  of  the  wet-nurse  physically,  and,  most  important 
of  all,  by  the  quality  and  quantity  of  her  breast-milk. 

Health  of  the  Wet-nurse. — It  must  be  borne  in  mind  that  the  secretion 
of  milk  does  not  so  much  depend  on  her  constitution  as  it  does  depend  on 
her  nervous  system.  Great  importance  must  therefore  be  placed  on  the 
vselessness  of  hysterical  or  neurasthenic  women  for  wet-nursing. 

The  phlegmatic  temperament — the  broad  shouldered,  easy-going  woman 
— pleasant  and  gentle  mannered,  is  the  one  most  useful  and  best  adapted  for 
wet-nursing. 

Wet-nurses  with  Goiter. — Be/.y,  of  Toulouse,  considers  the  question: 
Should  women  affected  with  goiter  be  accepted  as  wct-nuj-ses?  He  does  not 
think  so  because  there  is  a  certainty  of  danger  for  the  infant,  but  because  it 
is  more  prudent  to  exclude  such  women  from  nursing.  In  1S97  he  saw  a 
fatal  case  of  tetany  in  an  infant  aged  six  months  in  which  no  cause  could 
l)e  found  for  the  disease  except  the  fact  that  the  mother  who  nursed  this 
baby  had  exophthalmic  goiter.  A  few  montlis  later  he  saAV  another  case  of 
the  same  kind,  and  in  1898  he  saw  a  case  of  tetany  in  an  infant  aged  three 
months,  who  died  after  an  illness  of  about  forty  days  and  whose  nurse  had 
simple  goiter.  The  author  thinks  that  tetany  in  infants  may  be  of  thyroid 
origin,  and  that  the  thvroid  affections  of  tlic  nurse  are  transmitted  to  the 
inirslings.  He  does  not  ])retend  to  establish  an  invariab'e  law,  but  simply 
wishes  to  call  attention  to  the  possibility  of  such  transmission  and  to  suggest 
further  investigations  on  the  subject. 

We  should  reject  a  wet-nurse  as  unfit  for  nursing  if  she  has: — 


82  INFANT  FEEDING. 

1.  Enlarged  cervical  glands. 

2.  A  goiter. 

3.  Diseased  lungs,  no  matter  how  trivial. 

4.  Evidences  of  syphilis,  such  as  condylomata,  present. 

5.  Condylomata  on  her  genitals. 

6.  Mastitis. 

7.  Carious  teeth. 

Recurring  menstruation  is  no  contraindication  for  a  wet-nurse.  Some 
women  are  perfectly  healthy  and  will  menstruate  regularly  during  their 
period  of  wet-nursing,  without  harm  to  the  infant. 

Erosions  or  fissures  on  the  nipple  should  not  be  looked  upon  as  contra- 
indications for  wet-nursing.  Infants  will  thrive,  although  changed  from 
one  wet-nurse  to  another.  Breast-milk  is  not  uniform  in  its  consistency. 
We  know  that  its  ingredients  not  only  change  from  day  to  day,  but  that  the 
milk  varies  several  times  a  day.  In  spite  of  this  fact  children  thrive,  as 
was  demonstrated  by  Schlechter,  who  used  400  children  in  the  Vienna 
Foundling  Asylum,  Among  these  an  epidemic  of  gonorrhoeal  ophthalmia 
developed,  requiring  isolation.  Thus,  several  nurses  were  ordered  to  be 
isolated  with  these  infected  children,  and  it  was  noted  that  these  children 
developed  just  as  well  in  spite  of  the  change  from  their  previous  breast-milk. 

The  mortality  in  this  same  institution  resulting  from  feeding  with 
sterilized  milk  has  been  entirely  done  away  with  since  the  introduction  of 
wet-nursing. 

Finally,  it  is  important  to  note  that  it  is  the  quality  of  milk,  rather 
than  the  quantity,  which  determines  the  value  of  breast-milk. 

When  children  are  strong  and  well-built,  and  have  a  ravenous  appetite, 
they  require  a  slow-flowing  hreast-milk,  as  a  rapid  flow  of  breast-milk,  aided 
by  a  hearty  appetite,  will  tend  to  overload  the  stomach,  and  is  one  of  the 
reasons  for  dyspepsia  in  young  children. 

It  is  a  good  point  to  try  to  secure  a  wet-nurse  suckling  a  child  about  as 
old  as  the  one  we  wish  her  to  nurse,  although  it  is  quite  common  to  find 
nurses  who  have  older  children  than  the  one  they  wish  to  nurse,  and  to  find 
the  latter  doing  well. 

The  proof  of  the  usefulness  of  the  wet-nurse  is  the  condition  of  the  baby 
after  some  time.  If  the  child  thrives  it  will  increase  in  weight.  Hence 
scales  must  be  frequently  used.  The  milk  should  be  examined  by  a  chemist 
to  determine  the  percentage  of  ingredients. 

Especial  note  should  be  made  of  the  percentage  of  fat  and  proteids. 

If  a  very  quick  examination  is  required,  then  a  microscopical  examina- 
tion of  one  drop  of  middle-milk  will  show  the  character  of  the  fat  globules. 

The  rough  method  of  examination  is  useful  when  the  life  of  the  infant 
is  at  stake  and  it  is  necessary  to  determine  quickly  whether  or  not  a  given 
wet-nurse  is  suitable  for  an  infant.    If  a  baby  suddenly  appears  colicky  or 


INABILITY  TO  NURSR  83 

does  not  gain  in  weight  while  wet-nursing,  then  a  chemical  examination  of 
the  breast-milk  is  imperative,  "We  can  frequently  find  an  excess  of  fat  or, 
more  often,  an  excess  of  proteids  as  the  cause  of  colic. 

Von  Bunge  presents  the  results  of  an  investigation  in  which  he  shows 
that  the  increasing  inability  of  mothers  to  nurse  their  infants  is  a  matter 
of  inheritance.  He  obtained  information  relative  to  665  cases  with  the 
following  result :  The  daughter  was  able  to  nurse  her  offspring  in  182  cases. 
The  mother  was  able  in  99.2  per  cent.,  and  unable  in  only  0.8  per  cent. 
The  mother  was  able  in  237  cases.  The  daughter  was  able  in  53.2  per  cent., 
and  unable  in  46.8  per  cent.  The  daughter  was  unable  to  nurse  her  off- 
spring in  483  cases.  The  mother  was  able  in  43.2  per  cent.,  and  unable  in 
56.8  per  cent.  The  mother  was  unable  in  147  cases.  The  daughter  was 
unable  in  99.3  per  cent.,  and  able  in  0.7  per  cent. 

He  concluded  from  the  foregoing  figures  that  inability  to  nurse  is 
largely  a  matter  of  inheritance.  Further  inquiries  also  led  him  to  believe 
that  tuberculosis  and  nervous  diseases  were  to  a  considerable  extent  asso- 
ciated with  inability  to  nurse  one's  offspring.  But  much  more  prominent 
appears  to  be  the  relation  of  intemperance.  Where  the  mother  and  daughter 
were  both  able  to  nurse  he  found  that  the  fathers  were  usually  at  least  mod- 
erate in  the  use  of  alcohol,  and  only  in  4.5  per  cent,  were  they  hard  drinkers. 
On  the  other  hand,  when  the  mother  was  able  to  nurse,  but  the  daughter 
was  unable,  it  was  found  that  the  father  was  often  intemperate,  and  in  46.8 
per  cent,  was  an  actual  drunkard.  In  this  inquiry  the  author  considered 
those  only  as  able  to  nurse  who  could  nurse  all  their  children  for  a  period 
of  nine  months.    All  others  as  unable. 

The  control  of  wet-nurses  was  very  adequately  discussed*  as  a  public 
prophylaxis.  Many  believed  it  was  a  matter  that  could  be  brought  under 
the  control  of  the  law. 

Dr.  Petrini,  of  Galatz,  professor  at  the  University  of  Bucharest,  pre- 
pared an  elaborate  report  in  which  the  prevalence  of  infection  of  syphilis  by 
means  of  wet-nurses  was  demonstrated.  He  showed  that  its  frequency  varied 
widely  in  different  countries,  and  hence  an  English  view,  for  instance,  of  its 
comparative  importance,  drawn  from  the  rarity  of  the  infection  in  that 
country,  was  not  a  criterion  for  the  whole,  since  it  had  been  shown  for 
Oriental  lands,  and  even  for  Paris,  that  it  was  an  important  element. 

He  proposes  a  special  medical  service,  working  in  co-operation  with 
municipal  authorities  and  having  for  its  head  a  competent  syphilographer. 
All  children  being  nursed  by  wet-nurses  should  be  inspected  regularly  by 
representatives  of  this  bureau,  and  all  wet-nurses  should  receive  authoriza- 
tion for  their  calling  by  the  same  bureau  after  rigorous  medical  examina- 
tion.    Special  provision  should  be  made  for  syphilitic  children. 

*  Second  International  Conference  for  the  Prevention  of  Syphilis  and  Venereal 
Diseases,  held  at  Brussels,  Belgium,  September  1  to  6,  1902. 


84  INFANT  FEEDING. 


Clinical  Illustrations  of  the  Variations  in  Wet-nurses'  Milk. 

The  following  case  will  illustrate  the  peculiarity  of  breast  milk  in  a 
wet-nurse : — 

Case  I. — First  examination  of  bi"east-niilk  sliowed:  — 

Fat    2.50 

Milk-sugar  6.50 

Proteids    1.93 

Mneral  matter    21 

Total  solids 11.14 

Water    88.86 

When  the  wet-nurse  was  first  employed,  the  infant  eained  more  than  eight 
ounces  each  week.  Had  yellowish  stools,  one  or  two  each  day.  Slept  well  after 
nursing  and  appeared  satisfied.     Cried  only  at  feeding  time.     No  evidence  of  colic. 

A  second  examination  of  the  breast-milk  was  made  to  compare  the  character  of 
the  milk  with  that  of  the  first  specimen: — 

Fat 2.10 

Milk-sugar    6.50 

Proteids 1.41 

Mineial  matter    15 

Total  solids  10.16 

Water 89.84 

Two  months  later,  same  wet-nurse.  Child's  weight  stationary.  Green,  curded 
stools,  cries  and  has  colicky  pains.  Restless  at  night.  Wet-nurse  is  menstruating. 
Chemical  analysis  of  milk  shows  :^ — 

Fat    65 

Milk-sugar   6.50 

Proteids    1.12 

Mineral  matter   11 

Total  solids 8.38 

Water  91.02 

• 

With  the  aid  of  cereals  and  malt,  also  a  change  from  the  city  to  the  sea.shore, 
the  milk  improved.  The  infant  was  more  satisfied.  The  stools  again  assumed  a 
yellowish  color.  One  month  after  this  building-up  treatment,  an  analysis  of  the 
breast-milk  showed: — 

Fat 3.50 

Milk-sugar    6.50 

Proteids   190 

Mineral  matter   19 

Total  solids 12.09 

Water   87.91 


VARIATIONS  IN  BREAST-MILK.  85 

When  the  infant  was  eight  months  old  the  secretion  of  milk  was  scant}',  so 
that  the  breast  was  alternated  with  bottle-feeding.  The  general  condition  improved. 
The  child  was  again  satisfied.     A  chemical  examination  of  the  breast-milk  showed:  — 

Fat   3.00 

Milk-sugar    6.50 

Proteids 1.08 

Mineral  matter    19 

Total  solids 10.77 

Water    8Q.2.3 

As  the  proteids  were  found  to  be  very  low,  I  ordered  the  white  of  a  raw  egg, 
soup,  and  expressed  beef  juice.  When  the  child  was  nine  months  old  it  was  neces- 
sary to  wean  it,  as  the  wet-nurse  had  very  little  milk. 

In  this  case  the  stationary  weight,  the  colicky  condition,  and  the  char- 
acter of  the  stools  were  important  guides,  and  fully  agreed  with  the  analyses 
of  the  specimens  given. 

Case  II. — Colic. — An  infant  five  months  old.  suffered  with  severe  colic.  It  cried 
continuously,  especially  after  nursing.  Relief  was  afl'orded  when  castor-oil  was  given 
or  when  warm  colon  flushing  was  resorted  to.  Diluting  the  breast-milk  by  giving 
an  ounce  or  two  of  barley  or  rice  water  immediately  after  each  nursing  seemed  to 
modify,  but  not  altogether  relieve,  this  condition.  The  chemical  examination  of 
the  milk  gave:  — 

Fat 6.59 

Sugar 6.69 

Proteids   1.16 

Ash 1!) 

Total  solids 14.6:5 

Water    85.37 

The  excessive  amount  of  the  fat  ivas  evidently  the  cause  of  the  trouble.  The 
quantity  of  meat  Avas  reduced.  Exercise  was  ordered  and  beer  forbidden.  In  a  few 
weeks  the  ])erc('ntage  of  fat  in  the  milk  was  greatly  reduced,  and  the  infant  far 
more  comfortable. 

^Ooo        q, 


°     O    ^°  n      .        OO 
"     O  O     _,  ■•       OO 

o      O     o  (-.    r)    o      \       o 

**o      'Jo      o        oo';: 


C.VSE  Til. — Fig.   31. — Specimen  of  Breast-milk  Taken  from  a  Wet-nurse  during 
]\lenstruation,  illnstrating  the  Poor  Character  of  the  Emulsion.      (Original.) 


86  INFANT  FEEDING. 

The  infant  was  very  restless,  and  had  colicky  attacks.  Note  the  small,  un- 
evenly divided  fat  globules — irregular  form  of  the  larger  globules.  It  appears  to 
be  a  very  watery  emulsion.  Chemical  examination  of  the  specimen  showed :  Fat, 
1.(50;    sugar,  6.50;   proteids,   2.43.     The  baby  did  not  gain  during  the  whole  week. 

Case  1\*. — (ioocl  Milk  in  a  ^Yet-nu)^sc. — In  this  case  we  have  a  child  that  was 
gaining  in  weight.  Appeared  satisfied  after  nursing,  but  had  a  tendency  toward  con- 
stipation.    A  chemical  analysis  of  the  milk  gave:  — 

Fat    4.20 

Sugar    6.50 

Proteids     2.80. 

Ash .28 

Total  solids 13.78 

Water    86.22 

Diet  of  a  Wet-xurse. 

The  diet  given  for  a  nursing  mother  can  also  be  used  as  a  guide  in 
choosing  the  diet  for  a  wet-nurse.  The  greatest  care,  however,  must  be 
bestowed  on  the  manner  of  living. 

Planner  of  Living. — A  -wet-nurse  that  was  a  former  servant,  or  Avorked 
out  of  doors,  and  is  suddenly  taken  into  this  new  mode  of  life  and  given 
charge  of  a  baby,  must  have  proper  exercise.  Otherwise  she  will  very  soon 
secrete  milk  which  wall  be  totally  unfit  for  an  infant,  and  as  a  result  the 
child  will  probably  have  severe  colic  and  irregular,  cheesy  stools;  will  vomit 
excessively,  and  will  not  gain  sufficiently  in  weight.  It  is  therefore  impor- 
tant to  try  and  adapt  a  wet-nurse  to  the  same  condition  as  existed  prior  to 
her  pregnancy;  so  that  both  her  manner  of  living  and,  chiefly,  her  diet, 
shall  not  be  different. 

That  alcohol  may  be  eliminated  from  milk  is  shown  by  a  case  reported  by  Val- 
lani.  A  nursing  infant  was  seized  with  convulsions  with  great  regularity  on  Mon- 
day and  Thursday,  but  was  quite  well  on  other  days.  Investigation  showed  that 
the  wet-nurse  on  Sundays  and  Wednesdays  (her  days  out)  was  in  the  habit  of  drink- 
ing freely  of  alcohol.  The  curtailment  of  these  privileges  resulted  in  the  disappear- 
ance of  the  convulsions. 

Proper  Rest. — To  be  equal  to  her  task  a  nurse  must  be  given  plenty 
of  sleep,  if  it  is  at  all  possible. 

Adriance,  in  the  Archives  of  Pediatrics,  says: 

1.  Excessive  fats  or  proteids  may  cause  gastro-intestinal  symptoms  in 
the  nursing  infant. 

2.  Excessive  fats  may  be  reduced  by  diminishing  the  nitrogenous  ele- 
ments in  the  mother's  diet. 

3.  Excessive  proteids  may  bo  reduced  by  the  proper  amount  of  exercise. 

4.  Excessive  proteids  are  especially  apt  to  cause  gastro-intestinal  symp- 
toms during  the  colostrum  period. 


METHOD  OF  CHANGING  THE  INGREDIENTS  IN  WOMAN'S  MILK.      87 

5.  The  proteids,  being  higher  during  the  colostrum  period  of  prema- 
ture confinement,  present  dangers  to  the  untimely-born  infant. 

6.  Deterioration  in  human  milk  is  marked  by  a  reduction  in  the  pro- 
teids and  total  solids,  or  in  the  proteids  alone. 

7.  This  deterioration  takes  place  normally  during  the  later  months  of 
lactation,  and  unless  proper  additions  are  made  to  the  infant's  diet,  is 
accompanied  by  a  loss  of  weight  or  a  gain  below  the  normal,  standard. 

8.  When  this  deterioration  occurs  earlier,  it  may  be  the  forerunner  of 
the  cessation  of  lactation,  or  well-directed  treatment  may  improve  the  condi- 
tion of  the  milk. 

Methods  of  Changing  the  Ingredients  in  Woman's  Milk. 

Eotch  gives  a  condensed  table  for  these  changes  as  follows: — 

To  Increase  the  Toial  Quantity. — Increase  the  liquids  in  the  mother's 
diet,  especially  milk  (malt-extracts  may  be  helpful),  and  encourage  her  to 
believe  that  she  will  be  able  to  nurse  her  infant. 

To  Decrease  the  Total  Quantity. — Decrease  the  liquids  in  the  mother's 
diet. 

To  Increase  the  Total  Solids. — Shorten  the  nursing  intervals,  decrease 
the  exercise,  decrease  the  proportion  of  liquids,  and  increase  the  proportion 
of  solids  in  the  mother's  diet. 

To  Decrease  the  Total  Solids. — Prolong  the  nursing  intervals,  increase 
the  exercise,  and  increase  the  proportion  of  liquids  in  the  mother's  diet. 

To  Increase  the  Fat. — Increase  the  proportion  of  meat  in  the  diet. 

To  Decrease  the  Fat. — Decrease  the  proportion  of  meat  in  the  diet. 

To  Increase  the  Proteids. — Increase  the  exercise  up  to  the  limit  of 
fatigue  for  the  individual. 

It  is  wise  in  all  cases  of  disturhecl  lactation,  whether  in  maternal  or 
wet-nursing,  to  make  efforts  in  accordance  with  these  rules  to  produce  a  milk 
that  is  suitable  for  an  infant  who  is  not  thriving,  before  changing  to  any 
other  method  of  feeding. 

Wet-nursing. 

It  is  an  established  fact  that  the  best  possible  food  for  an  infant  rs 
breast-milk.  Where  the  mother  of  an  infant  is  prevented  from  nursing 
her  child,  the  next  thing  to  be  considered  is  wet-nursing.  That  nursing  a 
child  is  an  advantage  to  the  mother  is  a  well-known  fact,  inasmuch  as  it 
influences  the  contraction  of  the  uterus  and  stimulates  the  circulation. 
Contrary  to  the  belief  that  nursing  a  child  is  detrimental  and  contraindi- 
eated  in  women  whose  lungs  are  weak  and  who  have  a  tendency  to  tuber- 
culosis, it  docs  them  no  harm,  and,  indeed,  seems  to  do  them  good.  This 
statement  is  borne  out  by  the  experience  of  Dr.  Ileinrich  Munk,  of  Karls- 
bad, Austria,  a  specialist  in  the  diseases  of  women. 


88  DTFANT  FEEDING. 

In  Austria  the  state  supports  public  institutions  for  lying-in  women. 
They  are  kept  there  and  confined  gratis,  and  remain  about  fourteen  days. 
They  are  admitted  into  these  hospitals  in  the  last  months  of  J)regnancy. 
Vienna  usually  has  about  300  women  on  hand.  Prague  constantly  has  100 
women  in  this  condition,  who  are  utilized  for  the  purpose  of  instruction  to 
physicians  and  midwives. 

In  Prague  there  are  about  3000  women  confined  annually,  and  these 
women  are  put  into  the  foundling  asylum.  There  they  remain  until  they 
procure  a  place  as  a  wet-nurse  or  as  long  as  their  services  are  needed  in  the 
asylum.  When  wet-nurses  are  taken  from  the  foundling  asylum,  it  is  a 
frequent  occurrence  to  have  those  remaining  therein  nurse  at  least  two  chil- 
dren, and  frequently  three  at  one  time.  In  this  manner  they  dispense  grad- 
ually with  these  wet-nurses  without  hurting  the  remaining  children.  Many 
children  die,  some  of  them  intrapartum  in  operative  confinements,  and  the 
women  (mothers  of  such  children)  are  then  utilized  for  wet-nursing.  It 
is  a  rule  to  keep  the  children  in  the  asylum  until  they  have  attained  a  little 
over  4  kilograms  (about  9  pounds),  and  they  are  then  put  out  for  further 
feeding  (artificial  feeding),  for  which  the  city  pays  about  12  florins  ($5.00) 
a  month.  The  children  remain  usually  until  they  are  6  years  old,  and  are 
then  given  back  to  their  own  mothers.  Many  of  these  children  die,  others 
are  adopted  by  those  who  have  reared  them,  but  the  greater  portion  are 
taken  back  to  their  own  mothers.  In  Vienna  there  are  about  10,000  con- 
finements annually  in  the  public  institution.  There  are  a  great  many  cities 
in  Austria — like  Innsbruck-Olmutz,  Brunn,  Linz,  and  Klagcnfurt — where 
there  are  at  least  200  confinements  annually.  In  Vienna  a  wet-nurse  receives 
30  florins  per  month,  for  which  she  is  sent  (railroad  expenses  paid)  to 
whoever  requires  her  services.  She  is  taken  on  trial  for  fourteen  days  to  see 
if  she  is  adapted  for  her  place.  A  wet-nurse  can  be  procured  by  sending  a 
telegram  and  a  money  order  any  day  during  the  year.  The  customary  wages 
are  from  12  florins  upward  per  month.  Each  wet-nurse  is  carefully  exam- 
ined by  the  professor  before  she  is  sent  away.  A  great  many  families  do 
not  care  to  take  a  wet-nurse  from  an  asylum,  as  they  are  usually  women  of 
the  lowest  walks  of  life,  and  they  prefer,  therefore,  to  take  a  woman  who 
has  been  married.  For  this  purpose  agencies,  duly  licensed,  exist.  These 
will  supply  wet-nurses,  and  usually  take  orders  in  advance;  thus  a  wet- 
nurse  may  be  reserved.  Such  wet-nurses  cost  much  more,  and  those  from 
one  special  region — Iglau,  in  Mahren — receive  from  20  to  50  florins  monthly. 

The  Empress  took  a  wet-nurse  from  Iglau  (a  married  woman),  and 
the  Princess  of  Bulgaria  took  a  wet-nurse  from  Iglau  for  her  last  child. 
Not  only  Iglau,  but  the  whole  region,  is  renowned  for  its  excellent  quality 
of  wet  nurses.  Tlie  Bohemian  and  IMahron  niirsos  have  very  good  maramfe. 
They  seem  to  love  tlio  childi-cn  ciitrusied  to  them.  In  America  the  wet 
nurses  are  unodiioiitod  servants. 


WET-NURSING. 


89 


While  it  is  a  rule  that  a  wet-nurse  should  be  taken  for  a  baby  of  the 
same  age  as  that  of  her  own,  frequently  wet-nursing  of  an  infant  at  birth 
by  a  wet-nurse  whose  baby  is  three  months  old  has  not  been  followed  by  any 
bad  results. 

In  Xew  York  we  are  at  a  decided  disadvantage  regarding  wet-nurses. 
As  no  licensed  agents  exist,  a  few  people  having  so-called  influence  procure 
v;et-nurses  by  friendship,  or  something  similar,  from  superintendents  and 
house  physicians  where  obstetrical  work  is  done. 

Thus  we  find  ourselves  at  the  mercy  of  some  people  who  traffic  in  wet- 
nurses  for  a  fee,  usually  five  to  ten  dollars,  and  who  do  not  stop  at  anything 
to  attain  their  own  selfish  end. 


Fig.  32. — Pear-sliapecl  Breasts,  Best  Adapted  for  Nursing.      (Original.) 


Time  and  again  have  I  sent  for  a  wet-nurse  to  an  agent  who,  instead 
of  giving  me  a  healthy  wet-nurse,  tried  to  induce  me  to  use  women  having 
colostrum-milk  for  an  infant  in  which  such  milk  would  have  proved  dis- 
astrous. 

In  another  instance,  only  recently,  I  procured  a  wet-nurse  from  an 
agent  who  sent  me  a  girl  17  years  old,  who  had  had  a  premature  birtli, 
"evidently  an  abortion,"  and  whose  milk  was  thin  and  watcr}^,  with  here 
and  there  a  fat-globule  when  examined  under  the  microscope. 

At  other  times  some  of  the  finest  specimens  of  wet-nurses  have  been 
procured  from  Ihe  same  agent. 

It  is  a  pity  that  we  liave  no  municipal  control  for  what  (lie  writer 
considers  one  of  the  most  vnlual)le  adjuncts  to  our  infant-feeding,  and   in 


90  INFANT  FEEDING. 

the  same  manner  such  control  would  regulate  the  supply  to  such  unlimited 
number  that  modern  arrogance  on  the  part  of  the  wet-nurse  would  probably 
disappear. 

The  prices  paid  in  New  York  are  from  $20  to  $30  per  month  and  board, 
and  this  price  prohibits  many  an  infant  from  securing  the  benefits  of 
Nature's  food.     Let  us  hope  for  municipal  regulation. 

"Weaning  and  Feeding  from  One  Year  to  Fifteen  Months. 

Weaning  should  take  place  gradually  between  the  eighth  and  tenth 
months.  In  some  instances  it  is  advisable  to  commence  weaning  a  child 
much  sooner;  for  example,  when  there  is  a  deficiency  in  the  supply  Of  milk 
or  owing  to  ill  health  of  the  mother.  This  I  have  already  mentioned  in  the 
section  on  "Mixed  Feeding," 

Weaning  is  imperative  when  the  infant's  mother  is  pregnant,  although 
it  is  advisable  to  use  great  caution  if  it  occur  in  midsummer.  In  a  case  of 
this  kind  the  better  way  would  be  to  have  a  specimen  of  the  breast-milk 
examined  by  a  chemist,  and  if  the  same  be  found  deteriorated  in  quality, 
then  the  judgment  of  the  physician  must  prevail  as  to  the  advisability  of 
continuing  or  discontinuing  the  nursing.  My  rule  has  been  not  to  wean 
during  the  summer  months. 

The  main  points  have  already  been  mentioned  in  this  chapter  under 
"Wet-nurse." 

Weaning  should  not  be  attempted  suddenly.  It  is  better  to  commence 
weaning  gradually  by  withdrawing  the  breast  in  the  morning  and  substi- 
tuting the  bottle  for  that  meal.  Following  this  meal  we  can  again  nurse 
the  child  at  the  breast  for  two  more  feedings,  and  substitute  a  bottle  for 
its  fourth  meal  instead  of  the  breast. 

In  this  manner  we  can  feed  the  infant  with  a  bottle  in  the  morning, 
to  be  followed  in  three  or  four  hours  by  the  breast,  then  at  the  next  feeding 
again  nurse  the  child,  and  this  to  be  followed  in  three  or  four  hours  by  the 
bottle : — 

8.00  A.M Bottle. 

11.30  A.M Nursing. 

3.00  p.M Nursing. 

6.30  p.M Bottle. 

10.00   p.M Nursing. 

Thus  we  can  see  just  how  the  food  is  assimilated,  and  also  study  the 
individual  peculiarities  of  the  baby.  Some  children  are  very  hard  to  wean, 
and  it  will  require  great  tact  and  patience  to  successfully  cope  with  this 
condition. 


WEANING. 


91 


Case  I. — Difficult  Weaning. — A  child,  seventeen  months  old,  had  gi-eenish  stools, 
and  did  not  thrive.  His  body  weight  was  stationary.  He  was  restless  both  day 
and  night.  He  was  nursed  every  two  hours  and  cried  when  the  nipple  was  taken 
away.  The  chemical  examination  of  the  breast-milk  showed  about  one  per  cent,  of 
proteids  and  less  than  two  per  cent,  of  fat. 

In  this  case  the  prolonged  lactation  was  unsatisfactory.  The  wet-nurse  was 
anaemic,  and  consequently  her  milk  was  poor.  I  ordered  weaning  from  the  breast. 
The  child  refused  to  take  food  by  spoon  or  cup  and  would  spit  whenever  food  was 
forced  into  his  mouth.  It  was  necessary  to  place  the  child  in  charge  of  a  trained 
nurse  and  remove  the  wet-nurse  entirely  from  the  baby.  I  ordered  gavage  with 
equal  parts  of  milk  and  rice  water.  Six  ounces  were  given  at  one  feeding,  every 
four  hours.  After  two  days  of  continued  forced  feeding  (gavage)  the  child  took 
some  milk,  and  also  soup  from  a  cup. 

Case  II. — I  was  called  to  see  a  perfectly  healthy  child  about  nine  months  old, 
whose  mother  told  me  that  "Her  child  would  not  take  the  l>reast."  She  was  greatly 
chagrined,  but  all  efforts  at  nursing  him  proved  futile.  The  infant  had  weaned  him- 
self.    Such  cases  of  "self-weaning"  are  very  rare. 


Fig.  33.— Ideal  Feeding  Cup. 


When  weaning  is  successfully  accomplished,  then  great  care  must  he 
exercised  owing  to  the  change  in  diet.  It  will  be  found  that  the  slightest 
error  in  overfeeding  or  too  frecjuent  feeding  will  be  rewarded  by  a  severe 
attack  of  dyspepsia  and  the  usual  gastric  disturbances,  such  as  vomiting 
and  fermentation  in  the  stomach,  causing  diarrhoea  and.  possibly,  colic. 
It  will  therefore  be  very  necessary  to  exercise  good  judgment  in  the 
choice  of  both  quality  and  quantity  of  food  during  the  first  month  or  two 
after  weaning,  or  until  tlie  stomach  adapts  itself  to  this  new  way  of 
feeding.  2'he  (iini/lnli/lic  finicllnii  iiotr  heuKj  iJioroinjliIi/  developed,  we  can 
safclji  give  rerenls.     I  picfer  a  saucer  of  farina  steamed  at  least  two  hours. 

Time  of  Feeding. — Excepting  in  rare  instances,  after  a  child  is 
weaned  it  should  not  1)0  fed  oftener  than  once  in  four  hours.  The  best 
time  for  feeding  would  be  about  H  a.m..  K)  a.m..  "^  i'.m..  (i  I'.M.,  and  10  1'..m., 
ii  the  child  is  awake.     Tliis  would  uive  ei"ht  hours'  rest. 


92  INFANT  FEEUINC;. 

The  lirsi  bottle  after  sleej)ing  should  consist  ot  <S  ounces  of  i)ure 
cow's  milk.     This  wouhl  he  the  (i  A..M.  t't'cdinuj. 

Four  hours  later,  or  at  10  a.m.,  the  infant  should  receive  the  white  of 
a  raw  vgg  with 

Cows"  milk    5  ounces 

Barley  water    '.i  ounces 

(■ranuhited    siiyar     1    level   teaspoonful 

At  2  r.M.  our  fei'diuii'  should  consist  oT  8  ouiu-cs  of  pure  cows"  milk. 
1  usually  ])erniil  The  infant  to  niltlile  on  nju'-half  piect'  of  ordinary 
zwieliack. 

The  eveninti'  meal  at  <i  v.m.: — 

Cows'  milk    tl  ounces 

IJarlej'  water 2  ounces 

Granulated    sugar     1   level  teaspoon ful 

The  last  feeding,  at  10  p.m.  if  the  child  is  awake,  or  at  midnight, 
should  consist  of  8  ounces  of  pure  cows'  milk. 

When  milk  is  brought  from  the  dairy  there  is  a  thick  layer  of  cream 
on  the  to])  which  should  be  thoroughly  nii.xed  with  the  milk  by  shaking 
the  ])ottle,  so  that  the  infant  receives  a  thoroughly  mixed  milk  con- 
taining the  same  (puintity  of  cream  in  each  feeding.  The  milk  should  be 
mixed  and  tlu'  barley  water  added  to  it.  ]t  is  then  ])oured  into  thor- 
oughly cleaned  bottles,  which  are  stoppered  with  ordinary  cotton  stoppers. 
This  can  be  found  described  in  detail  in  the  chapter  on  "Sterilization." 
This  food  is  to  steam  for  twenty  minutes  and  then  allowed  to  cool  by 
placing  the  bottles  in  a  I'efrigerator,  but  not  on  the  ice.  When  ready  for 
use  each  bottle  is  to  l)e  warnu'd  to  a  temperature  of  100°  F.  for  the  feed- 
ing. If  constipation  follows  the  use  of  this  diet,  then  a  good  plan  is  to 
substitute  2  ounces  of  oatmeal  water  instead  of  the  barley  water  above 
mentioned.  When  the  stools  are  regidai'  but  the  child  appears  to  be 
(piite  pale,  tlum  great  good  can  be  accomplished  liy  adding  2  otinccs  of 
almond-milk  instead  of  the  oatuu'al  or  ha 'ley  water.  The  preparation  of 
a!niond-n)ilk  can  he  fonnd  desci'ihed  in  the  "Dietary,"  to  which  I  beg  to 
refer  my  readers.  If  a  severe  form  of  constipation,  with  cheesy  curds  in 
the  stools,  exists,  then  the  milk  shou'.d  not  be  steamed,  but  fed  in  the 
"raw  state."  It  is  to  be  understood  that  it  should  be  wanned  to  the  body 
heat,  before  feeding  to  the  infant.  Instead  of  giving  the  white  of  egg 
every  day  I  sul)stitute  either  1  or  2  ounces  of  beef  soup,  chicken  soup, 
beef  tea,  or  expressed  steak  juice,  and  feed  iliis  cpuintity  immediately 
before  the  10  A. At.  bottle  of  milk.  Xo  distinct  change  of  food  is  neces- 
sary until  the  child  is  twehc  oi'  fifteen  months  old,  when  1  am  in  the 
hahit  of  giving  either  a  half-saucer  of  oatmeal  gruel,  farina,  harley,  or 
hominy  and  butter,  in  addition  to  a  morning  bottle.     When  the  child 


:maxagemen't  of  wo^fax's  xtpples.   ^  93 

ai'rives  at  this  age  a  lialf-dozrn  teaspoon I'uls  of  junket  can  he  fed  before 
I  he  eveiimg  bottle  of  milk.  When  a  child  is  over  one  year  or  about  fifteen 
months  old,  instead  of  giving  water  for  thirst  I  frequently  give  prune- 
water  made  by  boiling  good,  fleshy  prunes  in  water  for  one-half  hour  and 
straining  off  the  liquid.  Wlien  oranges  can  be  procured,  one  or  more 
tablespoonfuls  of  juice  can  be  given  to  advantage.  Apple  sauce  can  also 
he  given.  Thus  my  plan  consists  in  giving  one  of  these  foocls  on  different 
davs.  Just  at  this  period  the  addition  of  several  teaspoonfuls  of  Eskay's 
food  has  been  found  very  beneficial.  Owing  to  gastric  derangements,  it 
will  be  found  necessarv'-  to  frecjuently  discontinue  milk  entirely.  At  such 
times  the  use  of  the  milk  foods,  such  as  Horlick's  food  and  Xestle's  food, 
has  proved  very  beneficial.  When  diluting  milk  with  cereals,  like  barley 
water,  rice  water,  sago  water,  flour  ball  and  water,  it  is  always  better  to 
dextrinize  the  diluents.  This  dextrinization  lias  a  decided  effect  on  the 
casein,  inasmuch  as  it  splits  up  the  curd,  rendering  it  finely  floceulent  as 
it  is  found  in  human  milk,  and  it  is  especially  indicated  in  the  period  of 
weaning  after  the  stomach  has  been  accustomed  to  breast-milk,  and  is 
suddenly  forced  to  digest  cows'  milk  containing  a  more  tenacious  and 
heavier  casein,  or  curd. 

The  Management  of  the  Nipples  Before  the  Baby  is  Born. — It  is  very 
important  during  the  last  few  months  of  pregnancy  to  devote  consider- 
able time  and  attention  to  the  condition  of  the  nipples.  If  these  be  found 
long  and  round,  well  projecting,  then  it  is  advisable  to  try  to  harden 
them,  because  the  irritation  from  the  child  will  cause  considerable 
trouljle  unless  we  seek  to  prevent  this. 

Oni,  in  treating  the  question  of  sore  nipples,  said  at  the  ^ledical 
Society,^  that  one  out  of  every  two  nursing  women  was  affected  with 
lesions  of  the  nipples.  The  determining  cause  of  the  fissures  was  macera- 
tion of  the  epiderm  under  the  doul)le  influence  of  the  saliva  of  the  infant 
and  the  milk  which  flowed  during  the  intervals.  The  ei)iderm  exfoliated 
and  the  derm  exposed  l)ecanie  excoriated  ;  the  lesion  thus  pi'oduced  became 
infected,  and,  instead  of  heiiling.  progressed  in  extent.  The  ]u-edisi)osing 
causes  were  short  and  inextensive  nipples  and  want  of  cleanliness.  The 
primii)ara3  were  affected  with  fissured  nipjfles  to  the  extent  of  59  per  cent. 

The  pr()|)]iylactic  treatment  consisted  in  astringent  lotions  during 
j)regnancy,  while  after  delivery  the  nipple  should  be  washed  with  boric 
acid  lotion  before  and  after  suction,  the  application  of  an  antisej)tic 
dressing  during  the  intervals  of  nursing.  The  curative  treatment,  to  l)e 
radical,  consisted  in  the  suspension  of  nursing,  whicli,  although  excellent 
for  the  mother,  would  be  de])lorable  for  the  child.  The  list  of  agents 
employed  against  the  fissure  was  very  lengthy,  indicating  their  uselessness. 


^  Paris  Cor.  !Mt'cl.  Press  and  f'irfular, 


94  INFANT  FEEDING. 

In  Slimmer  cold  water  will  be  found  more  agrecal)le,  with  a  small  qnan- 
tit}'  of  alcohol.  If  the  nipples  are  very  small  and  tiat,  and  do  not  protrude 
properly,  then  suction  by  means  of  a  breast-])um]),  applied  directly  over  tlie 
breast,  will  draw  them  out.  In  some  instances  an  ordinary  clay  pipe  which 
has  a  smooth  bowl,  the  bowl  to  be  laid  over  the  nipple  and  the  stem  to  be 
suclved  or  drawn,  is  satisfactory.  This  is  to  be  repeated  every  few  days. 
A  few  minutes  of  drawing  out  will  suffice  until  the  nipples  are  sufficiently 
prominent.  Biedert^  gives  the  following  prescrijition  for  hardening  the 
nipples : — 

Tannic  acid   1  teaspoonful 

Red  wine    8  ounces 

If  red  wine  is  not  handy,  then  substitute  brandy  in  its  stead.  This  is 
to  be  applied  after  thorough  washing  with  soap  and  water,  and  removing 
crusts,  if  they  are  present. 


Fig.  34. — Nipple-slueld  loi   Kt'liet  ot  Tender  Nipples. 

Tender  Nipples. — If,  while  nursing,  the  nipples  crack  and  blood  oozes 
from  them,  or  if,  from  irritation  of  the  child's  gums  biting  them,  the  nipple 
is  sore,  then  it  is  a  good  plan  to  allow  the  child  to  nurse  through  a  nii)])l.'- 
shiekl.     (See  Fig.  34.) 

Nipple-shields  can  be  used  during  the  nursing  act,  and  inunediatcly 
thereafter  the  following  salve  can  be  smeared  on  the  nipples: — 

I^  Zinc  oxide     1  drachm 

Vaseline   1  ounce 

TREATMENT    OF    TENDER    NIPPLES    (GARRIGUEs). 

R  Ortlioform     1  drachm 

Lanoline 1  ounce 

M.     Sig.:     Apply. 

Breast-pump. 
The  breast-pump  (Figs.  35  and  3f))  is  a  valuable  addition  to  the  nur- 
sery.   It  should  1)('  kept  scrupulously  clean  by  immersing  it  in  boiling  water 

'  "  Kinderemaehrung, "  fourth  edition,  1900,  page  110. 


BREAST-PUMP. 


95 


containing  a  pinch  of  table-salt.  In  drawing  a  specimen  of  breast-milk  for 
a  chemical  examination  the  breast-pump  is  very  useful.  If  an  infant  is  ill 
and  refuses  the  breast — as,  for  example,  if  it  has  rhinitis  or  cold  in  the  head, 
nasal  obstruction,  preventing  it  from  breathing  while  the  nipple  is  in  its 
mouth — it  generally  will  take  the  breast  and  immediately  let  go  of  it  again. 


Fig.  35. — Breast-pump. 

If  the  breast-pump  is  properly  applied,  and  the  required  quantity  of  milk 
drawn  off,  the  infant  can  frequently  be  fed  slowly  with  a  spoon. 

In  a  serious  condition — as,  for  example,  in  a  severe  case  of  pneumonia 
with  loss  of  appetite — the  life  of  the  child  may  depend  on  forced  feeding. 
This  will  be  described  in  the  section  on  "Gavage."    It  is  very  important  to 


Fig.  38. — Breast-pump. 

liavc  the  cup  or  any  other  receptacle  into  which  we  draw  the  breast-milk 
properly  sterilized;  otherwise  the  breast-milk  will  be  infected  in  the  s;ime 
manner  as  has  been  described  in  detail  in  the  sections  on  "Cows'  Milk"  and 
"Bottle-feeding." 


Massage  of  the  Breast  During  Lactation. 

Caking. — 'J'ho  "caking,"  or  hardening,  of  the  breast  is  not  due  to  curd- 
ling of  the  milk.    This  never  takes  place  within  the  milk-tubes,  nor  yet  to 


96  INFANT  FEEDING. 

the  presence  of  milk,  for  as  a  rule  no  milk  is  formed,  according  to  the  writer, 
until  nursing  begins,  or  if  any,  but  a  very  small  amount.  The  hardening 
of  the  gland  is  due  to  the  congestion  of  the  blood  and  lymph,  and  therefore 
massage  should  be  directed  to  the  removal  of  these,  and  likewise  should 
be  centrifugal  in  direction,  and  not  aim  to  the  removal  of  the  milk  by  centri- 
petal stroking.  The  blood  supply  of  the  gland  is  mainly  derived  from  the 
subclavian  and  axillary  arteries,  the  venous  outflow  and  the  lymph  discharge 
is  by  corresponding  channels,  and  this  is  the  anatomical  basis  for  action. 
The  massage  should  begin  gently  below  the  clavicle  and  in  the  axilla,  and 
gradually  encroach  more  and  more  on  the  mammary  region.  By  this  method 
a  hard  and  painful  breast  is  rendered  lax  and  comfortable  without  the  dis- 
charge of  any  milk.  The  writer  does  not  recommend  the  treatment  where 
there  is  infection  or  true  inflammation,  as  in  mastitis;  in  such  conditions 
rest  is  indicated  and  nothing  should  be  done  which  will  tend  to  spread  the 
infection.^ 

Peoteid  Indigestion  in  Nursing  Infants,  Causing  Colio 
AND  Constipation. 

1.  Colic. — One  of  the  most  frequent  disorders  in  nursing  infants  is 
colic.  This  colic  usually  appears  about  one  hour  after  cursing.  Sometimes 
it  appears  a  little  sooner,  sometimes  a  little  later.  Associated  with  this 
colic  is  the  usual  evidence  of  pain.  The  attack  appears  in  the  following 
manner:  In  about  an  hour  after  nursing,  the  child,  which  up  to  this  time 
has  been  quiet  or  asleep,  will  suddenly  awake  with  a  shriek  and  scream.  At 
the  same  time  it  will  draw  the  legs  on  the  abdomen,  get  very  red  in  the  face, 
and  continue  to  scream  for  a  few  minutes.  Such  an  attack  will  last  from 
fifteen  to  twenty  minutes;  at  other  times  as  long  as  one  hour.  Belief  is 
usually  afforded  by  gently  rubbing  the  abdomen  with  warmed  sweet-oil  or 
vaseline;  in  other  words,  by  using  gentle  massage.  Besides  the  oil,  an 
enema,  consisting  of  warm  water  and  glycerine,  or  warm  chamomile  tea, 
usually  affords  relief  by  removing  the  offending  and  undigested  caseine. 
The  stool  will  usually  be  found  to  contain  large  quantities  of  undigested 
cheese.     Small  white  particles  can  be  seen  scattered  through  such  stool. 

It  is  not  uncommon  to  find,  where  such  a  condition  exists,  that  the 
attacks  will  appear  after  each  nursing.  A  distinct  association  between  the 
condition  described  and  the  nursing  must  be  suspected.  When  this  condition 
is  suspected,  then  the  milk  must  be  examined  by  a  chemist  to  determine  the 
percentage  of  its  ingredients.  If  the  percentage  of  caseine  is  found  excessive, 
then  exercise  by  the  nursing  mother  will  be  called  for. 


*  See  an  elaborate  paper  on  this  subject  by  Bacon  in  American  Journal  of 
Obstetrics. 


PROTEID  INDIGESTION  CAUSING  COLIC  AND  CONSTIPATION. 


97 


Sometimes  reducing  the  iiitrogeiiovis  food  aad  drinking  large  quanti- 
ties of  liquid,  will  modify  the  amount  of  caseine,  so  that  the  milk  will  not 
be  so  concentrated.  If  the  child  continues  with  this  colicky  condition,  then 
we  must  instruct  the  mother  regarding  exercise.  It  is  well  to  give  the  infant 
a  small  quantity  of  oatmeal  water;  several  teaspoonfuls  will  suffice  after 
each  nursing.  In  other  instances  giving  the  baby  small  quantities  of  pan- 
creatine, or  a  combination  like  the  Fairchild's  peptonizing  powder,  will  be 
found  advantageous.  This  can  be  given  so  that  we  peptonize  the  food  and 
aid  in  the  digestion  and  assimilation  of  the  same. 

"We  are  dealing  with  mother  and  infant,  and  a  great  many  changes  will 
be  demanded.  Care  should  be  bestowed  upon  the  condition  of  the  mother's 
bowels.  The  slightest  constipation  should  be  modified  by  giving  her  a 
saline.  A  teaspoonful  of  Epsom  salts  in  the  morning,  repeated  in  the  even- 
ing if  necessary. 

She  should  eat  large  quantities  of  fruit,  such  as  peaches,  prunes,  grapes, 
aj^ples,  and  oranges. 

2.  Constipation. — Another  result  of  proteid  indigestion  is  constipation. 
When  we  are  told  that  large,  dry,  cheesy  curds  are  evacuated,  then  the  cause 
of  such  indigestion  should  be  sought. 

If  the  infant  is  nursing,  the  proper  method  to  pursue  is  to  examine  a 
specimen  of  breast-milk  under  a  microscope,  using  the  middle  milk  for  this 
purpose.  Submit  a  specimen  to  a  chemist  or  to  a  laboratory  and  note  the 
percentage  of  ingredients. 

If  there  is  a  deficiency  in  the  percentage  of  fat,  such  deficiency  can  be 
remedied  by  giving  the  baby  an  equivalent  of  cream.  If  there  is  a  deficiency 
of  carbohydrate,  we  increase  the  same  by  giving  the  baby  some  sugar.  When 
there  is  proteid  deficiency  we  can  modify  the  same  by  adding  raw  albumin 
(white  of  egg)  or  almond  milk,  pea  soup,  lentil  soup,  or  broth  made  of  meat. 

The  above  will  give  a  choice  between  animal  or  vegetable  proteids. 

Infant  Mortality  and  a  Study  of  the  Mode  of  Feeding. 


Table  No.   16. — Ecf/iHtrar  General — England  and  Wales,  1890-94. 


Year. 

Total 
Births. 

Total 
Deaths. 

Deaths  Under 
1  Year. 

Deaths  from 
Diarrhoea. 

Deaths  from 

Diarrhoea 
Under  1  Year. 

1890       

1W91       

1892      

1893      

1894      

869,937 
914,157 
897,957 
914,572 
890,289 

.502,248 
587,925 
559,684 
569,958 
498,827 

130,9.55 
135,801 
132,463 
145,061 
121,799 

17,8.37 
13,962 
15,336 
29,721 
10,763 

11,795 

9,200 

10,487 

20,722 

7,360 

98 


INFANT  FEEDING. 
Table  No.  \l.—3foriaUty  Table  for  London,   1890-94-. 


Year. 

Total 
Births. 

Total 
Deaths. 

Deaths  Under 
1  Year. 

Deaths  from 
Diarrhoea. 

Total  Under 
1  Year. 

1890 

1891 

1892 

1893      

1894      

128,161 
134.484 
132,328 
133,062 
131,454 

87.689 
89, 122 
86,833 
89,707 
75,635 

20,944 
20,776 
20,441 
21,814 
18,812 

2,823 
2,496 
2,642 
3,546 
1  771 

1,983 
1,829 
1,884 
2,601 
1.324 

Table  No.  18. — Deaths  Due  to  Diarrhoea  and  Mode  of  Feeding  {Cameron). 


Cases 
Investigated. 

Percentage  of  the  153. 

Age  in  Months, 

On  Breast 
Only. 

On  Breast 
Partially. 

On  Bottle. 

0-  3      .                

41 
55 
34 
23 

153 

24 

16 

3 

30 

18 

20 

13 

9 

17 

14 

56 

3-6 

71 

6-9 

88 

9-12 

52 

68 

Eross  collected  statistics  from  sixteen  cities  of  Europe,  and  found  that 
of  1,439,056  children  born,  there  died  130,610  during  the  first  four  weeks 
of  their  life,  or  nearly  10  per  cent. 

Table  No.  19. — 7\oo  Hundred  Deaths — Their  Mode  of  Feeding  [Louis  Fischer).  Inquiry 
into  SOO  Deaths,  Taken  at  Random  at  the  Children's  Service  of  the  German  Foliklinik 
and  West  Side  German  Dispensary. 


Age  in  Months. 

Cases 
Investigated. 

On  Breast 
Only. 

On  Breast 
Partially. 

Bottle  Feeding 
Only. 

0-3 

3-6              .... 

6-  9  .    .    

9-12      

78 
30 
64 
28 

200 

5 

7 

12 

9 

33 

8 
12 
16 
12 

48 

65 
11 
36 

7 

119 

The  above  children  were  inhabitants  of  both  the  East  and  West  Side 
of  New  York  City,  living  in  crowded  apartments.  The  hygienic  factor  is, 
therefore,  an  important  one.  Sixty  per  cent,  of  these  children  died  from 
gastric  and  intestinal  disease.  About  30  per  cent,  died  from  catarrhal  dis- 
eases affecting  the  air  passages,  such  as  bronchitis,  pneumonia,  and  tuber- 
culosis.   The  rest  died  from  infectious  diseases  and  surgical  accidents. 


CHAPTER  II. 

COWS'  MILIC 

Hammersten*  gives  the  following  analysis  of  cows'  milk  in  a  thou- 
sand parts  as  follows: — 

Water   874.2 

Solids    125.8 

Fat 36.5 

Sugar 48.1 

Salt   7.1 

Proteid  (casein,  28.8;   albumin,  5.3) 34.1 

A.  Baginsky^  gives  the  following  analysis  of  cows'  milk,  made  at  the 
Kaiser  and  Kaiserin  Friedrich  Hospital,  Berlin: — 

Water  87.60 

Solids    12.38 

In  one  hundred  parts. 

The  solids  consist  of: — 

Casein  and  albumin  3.65 

Butter    3.11 

Milk-sugar  4.54 

Inorganic  salts    1.08 

Besides  large  amounts  of  potassium  and  potassium  salts  and  small 
quantities  of  iron. 

Composition,  Variation,  and  Production. — Milk  of  all  animals,  roughly 
speaking,  is  composed  of  the  same  ingredients,  but  an  analysis  of  milk  is 
apt  to  be  very  misleading,  as  it  does  not  show  the  physical  condition  of  the 
milk,  which  is  the  important  thing  to  know  from  the  physician's  standpoint. 

The  general  ingredients  of  milk  are  fat,  sugar,  albumin,  casein,  salts, 
and  water.  These  ingredients  vary  in  quantity  from  day  to  day,  and  from 
milking  to  milking.  An  average  analysis  of  a  woman's  milk  does  not  show 
what  an  infant  is  getting,  by  any  means,  for  the  composition  of  the  milk 
depends  upon  the  food,  the  health  of  the  mother,  and  the  frequency  of 
nursing. 

The  Breed  of  a  Cow.  —  Some  breeds  yield  quantity,  others  quality. 
Holsteins  produce  the  most  milk;  Alderneys  and  Jerseys  yield  the  most 
fat;  Shorthorns  give  the  most  casein  and  sugar.  The  average  capacity  of 
a  cows'  udder  is  about  5  pints,  and  the  annual  yield  of  milk  is  about  600 
gallons. 


•  "Physiological  Chemistry." 

•  "Diseases  of  Children,"  1899,  page  32. 


(99) 


100  INTANT  FEEDING. 

Time  and  Stage  of  Milking. — Cows  are  usually  milked  twice  a  day, 
the  morning  milk  usually  being  larger  in  quantity  and  poorer  in  quality. 
The  milk  which  is  first  drawn  is  known  as  the  fore-milk,  and  contains  very 
much  less  fat  than  that  last  drawn,  known  as  the  strippings.  This  is  due 
to  a  partial  creaming  taking  place  in  the  udders.  Dishonest  dealers  have 
often  taken  advantage  of  this  fact  in  adulteration  cases  to  have  the  cows 
partially  milked  in  the  presence  of  ignorant  witnesses,  the  resulting  milk 
consisting  largely  of  the  fore-milk. 

Age  of  Cows. — Young  cows  give  less  milk,  while  cows  from  four  to 
seven  years  old  give  the  richest  milk,  and  less  milk  is  given  with  the  first 
calf.  They  give  the  largest  yield,  according  to  Fleishmann,  after  the  fifth 
until  the  seventh  calf;  after  the  fourteenth  calf  they  yield,  as  a  rule,  no 
more  milk.  The  poorest  milk  is  yielded  during  the  spring  and  early  sum- 
mer; the  richest  during  the  autumn  and  early  winter.  If  cows  are  worried 
or  driven  about,  the  quality  and  quantity  of  the  milk  are  reduced.  If  they 
are  kept  warm  and  well  fed,  both  quantity  and  quality  are  naturally  in- 
creased. 

According  to  Rotch,  the  Durham,  or  Shorthorn,  represents  the  best  type 
of  cow  for  this  purpose.  She  has  great  constitutional  vigor,  great  capacity 
for  food,  a  perfect  digestion,  and  most  important  of  all,  a  quiet  tempera- 
ment.   The  analysis  of  her  milk  is  as  follows : — 

Per  cent. 

Fat 4.04 

Sugar    4.34 

Proteids    4.17 

Mineral  matter 0.73 

Total  solids 13.28 

Water    86.72 


100.00 


The  Devon  is  another  breed  of  cow  having  the  same  characteristics  as 
the  Durham.  They  are  gentle  and  vigorous,  and  yield  a  large  quantity  of 
rich  milk,  the  analysis  of  which  is  as  follows : — 

Per  cent. 

Fat 4.09 

Sugar    4.32 

Proteids 4.04 

Mineral  matter   0.76 

Total  solids 13.21 

Water  86.79 

100.00 


OOWS'  IkHLK.  101 

The  Ayrshire,  another  type,  while  representing  strength,  is  somewhat 
nervous,  and  while  not  as  hardy  as  the  Durham,  they  are  free  from  disease 
and  yield  a  large  quantity  of  milk,  the  analysis  of  which  is  as  follows : — • 

Per  cent. 

Fat  3.89 

Sugar 4.41 

Proteids   4.01 

Mineral  matter   0.73 

Total  solids  13.04 

Water   86.96 


100.00 


The  Holstein-Fnesian,  commonly  called  Holstein,  represents  the  most 
perfect  type  of  cow.  She  yields  a  large  quantity  of  milk,  though  light  in 
its  total  solids.     The  following  is  the  analysis: — 

Per  cent. 

Fat    2.88 

Sugar    4.33 

Proteids   3.99 

Mineral  matter    0.74 

Total  solids  1194 

Water 88.06 

100.00 

Some  of  the  marks  which  distinguish  the  breeds  of  cows  best  adapted 
for  infant  feeding  are : — 

1.  Constitutional  vigor.. 

2.  Adaptability  to  acclimatization. 

3.  Notable  ability  to  raise  their  young. 

4.  Freedom  from  intense  inbreeding. 

5.  A  distinctly  emulsified  fat  in  the  milk. 

6.  A  preponderance  in  the  fats  of  the  fixed  glyceridcs  over  the  vola- 
tile glycerides. 

The  volatile  glycerides  do  not  exist  in  the  mammae,  but  are  formed 
in  the  milk  soon  after  milking.  In  some  breeds,  as  in  those  of  the  Channel 
Islands,  this  change  occurs  more  quickly  than  in  others.  Such  breeds  as  the 
Jersey,  Guernsey,  and  any  others  in  which  intense  inbreeding  has  been  car- 
ried on,  and  in  which  acclimatization  has  not  been  perfected,  should  not 
be  used  for  infants  and  young  children.  These  breeds,  of  course,  do  not 
represent  all  of  those  available  for  substitute  feeding,  for  we  may  mention 
many  others  equally  good  each  in  its  country.  For  example,  the  Kerry, 
of  Ireland ;  the  Red  Polled,  of  England ;  the  Dutch  Belted,  and  the  Flem- 
ish; also,  the  Flamande  and  the  Cotcntine,  of  France;  the  Norman  breed. 


102  INFANT  FEEDING. 

of  Normandy;  besides  the  Sirmenthal,  sometimes  called  Bernese,  of  Switzer- 
land; together  with  the  Chianina,  of  Italy,  and  the  Allgauer,  of  Germany. 
The  native  cow  of  this  country,  the  ''lied  Cow,''  through  many  generations 
of  neglect  and  exposure  in  winter,  has  undoubtedly  acquired  an  impaired 
digestion,  and  does  not  respond  readily  to  appropriate  changes  of  food. 

Care  of  the  Cow. — Knowing  the  cow  to  be  a  sensitive  animal,  she 
should  be  carefully  guarded  from  useless  excitement.  She  should  be  care- 
fully groomed  by  cleaning  and  washing,  and  the  parts  should  be  thoroughly 
dried.  The  barn  should  have  plenty  of  fresh  air  and  the  sunlight  should  be 
admitted.  There  should  be  plenty  of  room  for  exercise.  In  the  stalls  the 
cow  should  have  perfect  freedom  for  her  head  and  limbs.  The  food  a  cow 
receives  should  be  wholesome  and  varied.  She  should  never  be  fed  with  the 
by-products  of  brewery  or  glucose  factories.  The  food  best  adapted  for  the 
cow  is  hay,  wheat,  bran,  ground  oats,  and  cornmeal.  In  winter  sugar  beets 
and  carrots  may  be  added.  Much  care  is  needed  to  graduate  the  change  from 
green  foods  to  dry,  as  disturbance  of  the  equilibrium  of  the  mammary 
gland  is  followed  by  injurious  effects  to  the  consumer.  We  should  strive 
to  give  a  cow  green  clover,  green  corn,  green  oats,  and  meadow  grass.  Poi- 
sonous weeds  must  be  guarded  against.  Not  infrequently  we  read  of  gastro- 
enteric conditions  in  children,  which  are  traceable  to  poisonous  weeds.  Pm-e 
water  in  large  quantities  must  alivays  he  at  hand.  A  cow  is  best  adapted 
for  the  production  of  milk  between  her  third  and  ninth  years.  The  milk 
of  a  cow  is  not  adapted  for  infant  feeding  until  it  is  free  from  colostrum 
corpuscles.    It  should  not  be  used  in  the  advanced  stage  of  pregnancy. 

Tuberculin-  Test. — Every  dairy  now  resorts  to  prophylactic  measures, 
hence  none  should  be  employed  that  has  not  been  subjected  to  the  tuber- 
culine  test.  Besides  this,  each  cow  should  be  examined  by  a  skilled  veteri- 
narian regarding  her  physical  condition. 

Care  of  the  Milk. — The  vital  point  consists  in  excluding  germs  and 
barn  filth.  The  Milk  Commission  of  New  York  has  tentatively  fixed  upon 
a  maximum  of  30,000  germs  of  all  kinds  per  cubic  centimeter  of  milk.  A 
cubic  centimeter  is  about  one-half  a  teaspoonful,  and  a  quart  of  milk  con- 
tains about  900  cubic  centimeters,  so  the  total  number  of  germs  in  a  quart 
must  be  less  than  27,000,000. 

This  standard  must  not  be  exceeded  in  order  to  obtain  the  endorsement 
of  the  Commission,  and  must  be  attained  solely  by  measures  directed  toward 
scrupulous  cleanliness,  proper  cooling,  and  prompt  delivery. 

Furthermore,  the  milk  certified  by  the  Commission  must  contain  not 
1g?p  than  four  per  cent,  of  butter  fat,  on  the  average,  and  have  all  other 
characteristics  of  pure,  wholesome  milk. 

In  order  that  dealers  who  incur  the  expense  and  take  the  precautions 
necessary  to  furnish  a  truly  clean  and  wholesome  milk  may  have  some  suit- 
able means  of  bringing  these  facts  before  the  public,  the  Commission  offers 


CERTIFIED  MILK,  103 

tliem  the  right  to  use  caps  on  their  milk  jars  stamped  with  the  words: 
"Certified  by  the  Commission  of  the  Medical  Society  of  the  County  of  New 
YorJc." 

Eowland  G.  Freeman,  answering  an  inquiry  of  mine  concerning  the  pos- 
sibility of  procuring  milk  free  from  germs  in  the  dairy,  says :  "By  means  of 
special  methods  it  has  been  found  possible  in  some  cases  to  obtain  milk 
with  only  10  bacteria  per  cubic  centimeter.  These  methods  are,  however, 
not  practicable  for  a  large  commercial  supply.  When  the  conditions  at  the 
dairy  are  known  to  be  good  a  bacterial  content  averaging  less  than  5000 
per  cubic  centimeter  has  seemed  to  me  satisfactory,  while  a  bacterial  content 
averaging  less  than  10,000  is  fairly  good." 

Thus  it  appears,  that  with  excellent  care,  as  described  in  the  handling 
of  milk,  with  modern  hygiene,  practically  sterile  milk  can  be  procured  for 
Infant  feeding. 

Certified  Milk  in  New  York. 

The  dairy  rules  of  the  United  States  Department  of  Agriculture  de- 
scribe in  detail  the  caring  and  feeding  of  cattle.  It  was  decided  that  the 
acidity  of  milk  should  not  be  higher  than  0.2  per  cent.,  and  that  the  num- 
ber of  bacteria  should  not  be  more -than  30,000  per  cubic  centimeter. 

The  Eockefeller  Institute  for  Medical  Eesearch  inaugurated  a  periodical 
inspection  of  the  dairies  and  milk  of  the  dealers  who  were  willing  to  co- 
operate to  secure  a  clean,  fresh  milk. 

It  was  observed  that  the  milk  from  a  cow  milked  in  a  dirty  barn  showed 
120,000  bacteria  to  the  cubic  centimeter,  while  another  cow  of  the  same 
herd  milked  in  a  pasture  gave  milk  with  only  26,000.  A  cow  standing  near 
a  pile  of  dry  feed  had  1,000,000  bacteria  per  cubic  centimeter,  while  the 
milk  of  other  cows  had  a  low  bacterial  count.  Dirty  cows  gave  a  much 
higher  count  of  bacteria  than  clean  ones.  Clean  cows  in  a  herd  gave  a  count 
of  2000  as  against  90,000  in  the  milk  of  the  dirty  cows.  The  milker  was 
frequently  found  to  be  dirty,  and  the  milk  from  some  milkers  always  gave 
a  high  bacterial  count.  With  the  utensils  it  was  sometimes  difficult  to  find 
which  factor  was  at  fault.  The  ordinary  strainer  was,  however,  a  prolific 
source  of  bacteria. 

With  a  sterile  pail  and  a  sterilized  cotton  or  cheese-cloth  strainer  the 
bacteria  would  fall  in  numbers.  Aeration  by  requiring  more  complicated 
apparatus  increased  the  danger  of  contamination.  This  was  particularly 
so  if  aeration  was  carried  out  in  a  dirty  barn  or  without  regard  to  strict 
cleanliness. 

The  process  of  rapid  cooling  is  one  of  the  most  important  factors  in 
the  production  of  uncontaminated  milk.  The  cooling  of  milk  in  springs 
is  seldom  sufficient,  as  the  temperature  of  water  in  summer  was  found  to 
vary  from  45°  F.  to  70°  F.,  whereas  the  milk  should  be  brought  below  45°  F. 


104  INFANT  FEEDING. 

to  insure  few  bacteria.  Ice  is  absolutely  necessary  to  the  farmer  who 
handles  milk.  W.  H.  Park  (Yale  Medical  Journal)  says,  as  to  the  number 
of  bacteria  in  the  city  milk:  "From  an  examination  of  nearly  1000  speci- 
mens there  is  no  question  about  the  enormous  number  of  bacteria  present  in 
the  city  milk.  Now  as  to  the  harmfulness  of  this  milk :  The  group  of  chil- 
dren under  1  year,  on  heated  milk,  received  from  decent  farms,  running 
before  heating  from  1,000,000  to  5,000,000  bacteria  per  cubic  centimeter, 
did  not,  so  far  as  we  could  see,  suffer  any  serious  harm  from  the  bacterial 
products  in  the  milk.  During  the  summer  these  children  had,  off  and  on, 
intestinal  disorders,  but  not  much  more  than  those  in  the  same  section  of 
the  city  receiving  milk  from  the  very  best  possible  dairies  around  New  York. 
The  children  on  pasteurized  milk  showed  some  very  interesting  results. 
"There  were  very  few  bacteria  in  this  milk  when  first  received — any- 
where from  10,000  to  20,000 ;  but  on  the  second  day  they  had  so  increased 
as  to  be  from  10,000,000  to  30,000,000.  In  some  cases  where  the  second 
day  milk  was  given  there  was  immediate  vomiting,  followed  by  diarrhoea. 

"Bacterial  Count  of  Milk  Bought  in  a  Public  Park  During  the  Summer  of  190ff. — 
One  cubic  centimeter  of  Strauss's  sterilized,  modified  milk  contained  22,624  bacteria. 
Growth  of  colonies  was  upon  nutrient  gelatine,  and  count  was  made  thirty-six  hours 
after  growing  the  plate. 

"In  the  asylums,  where  the  children  were  from  3  to  13  years  of  age, 
we  found  no  trouble  from  the  milk  during  the  summer  months,  although 
in  some  cases  it  ran  as  high  as  100,000,000  bacteria  per  cubic  centimeter. 

"As  controls,  we  watched  infants  in  the  hospitals  and  in  the  tenements 
taking  breast-milk,  and  these  not  infrequently  developed  intestinal  disorders, 
showing  that  we  could  not  in  all  infants  taking  cows'  milk  attribute  these 
disorders  to  the  milk  impurities.  Altogether  it  seems  that  fairly  numerous 
bacteria  in  milk  obtained  from  clean,  healthy  cows  living  on  good  farms,  do 
not  cause  harm  in  the  older  children  and  the  products  do  not  cause  much 
harm  to  younger  children  when  subjected  to  heat.  When  milk  contaminated 
badly  and  improperly  kept,  so  that  the  bacteria  greatly  multiply,  is  fed  to 
babies,  they  do  badly,  and  it  seems  that  much  of  the  mortality  is  due  to 
poisonous  conditions  of  the  milk  developed  by  the  bacteria. 

"The  reasons  for  the  enormous  development  of  bacteria  in  the  milk  were 
insufficient  cleanliness  in  getting  the  milk  and  very  faulty  cooling  arrange- 
ments. The  farmers  mostly  put  their  milk  in  springs;  as  the  summer 
advances  the  water  gets  higher  in  temperature  until  it  reaches  about  60° 
F.  Some  farmers  hardly  cool  their  milk  at  all.  The  author  has  seen  milk 
shipped  in  cans  standing  in  a  car  where  the  temperature  was  90°  F.,  and 
left  there  without  any  ice  for  seven  hours.  The  City  Health  Board  has 
passed  a  rule  that  all  milk  shall  be  at  a  temperature  of  50°  F.,  or  under, 
when  it  reaches  New  York  City. 


TUBERCULOUS  INT^CTION  THROUGH  MILK.  105 

''The  Health  Department  found  that  milk  from  a  decent  farm  properly 
cooled  will  not  run  over  100,000  bacteria  per  cubic  centimeter  at  the  end 
of  twenty-four  hours,  and  that  such  milk,  if  kept  for  two  days  at  45°  F., 
will  not  run  more  than  200,000.  Therefore,  all  milk  that  runs  over  100,000 
bacteria  per  cubic  centimeter,  has  certainly  not  been  kept  in  a  proper  con- 
dition, and  such  a  number  of  bacteria  indicates  faulty  methods  of  caring  for 
the  milk.  The  Health  Board  has  passed  a  resolution  saying  that  milk  con- 
taining excessive  numbers  of  bacteria  is  unwholesome  and  should  not  be  sent 
to  New  York." 

Extract  from  the  "Sanitary  Code,"  Department  of  Health, 
City  of  New  York,  1901. 

"No  milk  which  has  been  watered,  adulterated,  reduced,  or  changed  in 
any  respect  by  the  addition  of  water  or  other  substance,  or  by  the  removal 
of  cream,  shall  be  brought  into,  held,  kept,  or  offered  for  sale  in  the  city 
of  New  York;  nor  shall  any  one  keep,  have,  or  offer  for  sale  in  the  said  city 
any  such  milk. 

"The  term  'adulterated,'  when  used  in  this  section,  means: — 

"First. — Milk  containing  more  than  88  per  centum  of  water  or  fluids. 

^'Second. — Milk  containing  less  than  12  per  centum  of  milk  solids. 

"Third. — Milk  containing  less  than  3  per  centum  of  fats, 

"Fourth. — Milk  drawn  from  animals  within  fifteen  days  before  or  five 
days  after  parturition. 

"Fifth. — Milk  drawn  from  animals  fed  on  distillery  waste,  or  any  sub- 
stance in  a  state  of  fermentation  or  putrefaction,  or  on  any  unhealthy  food. 

"Sixth. — Milk  drawn  from  cows  kept  in  a  crowded  or  unhealthy  condi- 
tion. 

"Seventh. — Milk  from  which  any  part  of  the  cream  has  been  removed. 

"Eighth. — Milk  which  has  been  diluted  with  water  or  any  other  fluid, 
or  to  which  has  been  added  or  into  which  has  been  introduced  any  foreign 
substance  whatever. 

"Ninth. — Milk,  the  temperature  of  which  is  higher  than  50°  F." 

Tuberculous  Infection  Through  ^Milk. 

The  question  of  tuberculous  infection  by  ingestion  of  milk  is  answered 
in  the  negative  by  N.  Aspe  {Rev.  d.  Med.  y  Cir.  Frac,  Nov.  21,  1901).  If 
the  tubercle  bacillus  reaches  the  cow's  udder,  it  must  necessarily  be  carried 
thither  by  tlie  blood.  The  bacillus  has  yet  to  be  found  in  the  blood ;  but, 
supposing  its  presence  there,  we  are  taught  to  believe  that  every  gland  in 
the  body,  by  its  selective  power,  takes  from  the  blood  only  those  elements 
which  are  necessary  to  the  elaboration  of  its  peculiar  products.  This  would 
seem  to  dispose  of  the  possibility  of  infection  of  the  milk  before  it  leaves 


106  INFANT  FEEDING. 

the  cow's  body,  unless  the  elective  faculty,  attributed  to  other  glands,  be 
denied  to  the  mammary.  Granting  this  possibility,  if  we  recall  that  in  the 
production  of  experimental  infections  by  subcutaneous  inoculation,  the  first 
organs  to  be  affected  are  the  lymphatics,  it  is  natural  to  suppose  that  the 
first  and  invariable  effect  of  the  ingestion  of  tuberculous  milk  would  be  the 
development  of  tabes  mesenterica,  yet  primary  tabes  is  comparatively  rare. 
The  author  of  this  paper  further  raises  the  question  of  identity  between  the 
human  and  bovine  tubercle  bacillus,  and  quotes  experiments  in  inoculation 
of  cows  with  cultures  from  human  tuberculous  products  with  negative  results 
in  the  nineteen  animals  experimented  upon,  whereas,  animals  injected  with 
the  bovine  form  quickly  succumbed,  and  autopsy  showed  tuberculous  lesions. 

The  Influence  of  High  Temperature  on  Tubercle  Bacilli  in  Milk. — ■ 
Barthel  and  Stenstrom  {CentralJ)lt.  f.  Bald.,  October  8,  1901),  in  reviewing 
recorded  experiments  on  the  sterilization  of  tuberculous  milk,  remark  on  the 
very  variable  results  obtained  by  different  observers.  Bang  has  stated  that 
heating  tuberculous  milk  to  80°  C.  is  not  sufficient  to  kill  the  bacilli,  but 
that  a  temperature  of  85°  C.  is  sufficient  for  the  purpose.  Forster  has  found 
70°  C.  for  five  to  ten  minutes  capable  of  killing  the  organisms;  De  Man,  70° 
C.  for  ten  minutes,  and  80°  C.  for  five  minutes.  Galtier  has  shown  that  milk 
submitted  to  70°,  75°,  80°,  and  85°  C.  for  six  minutes,  is  still  capable  of 
conveying  infection,  and  others  have  had  similar  results.  Barthel  and  Stens- 
trom have  conducted  experiments  which  go  to  show  that  the  chemical  reac- 
tion of  the  miUv  has  much  to  do  with  the  facility  ivith  which  it  is  sterilized. 
The  material  was  obtained  from  a  cow  with  an  udder  in  an  advanced  state  of 
tuberculosis.  Guinea  pigs  were  used  to  test  the  results,  and  the  effect  of 
65°,  70°,  75°,  and  80°  C.  were  studied.  The  results  were  positive  in  all 
cases;  that  is  to  say,  a  temperature  of  80°  C.  for  ten  minutes,  a  temperature 
of  75°  C.  for  fifteen  minutes,  70°  C.  for  fifteen  minutes,  and  65°  C.  for 
twenty  minutes  were  all  incapable  of  sterilizing  the  milk.  Tliese  results 
the  authors  interpret  as  follows:  Storch  has  shown  that  the  chemical 
changes  in  milk  are  the  more  marked  the  more  advanced  the  disease  of  the 
udder,  and  that  the  reaction  becomes  more  and  more  markedly  alkaline. 
On  the  other  hand,  it  has  long  been  known  that  it  is  more  difficult  to  sterilize 
an  alkaline  than  a  neutral,  and  a  neutral  than  an  acid  fluid.  The  specimen 
with  which  they  worked  was  strongly  alkaline,  and  to  this  they  ascribe  the 
difficulties  in  its  sterilization.  Variations  in  chemical  reaction  explain,  in 
their  opinion,  the  variations  in  the  results  obtained  by  other  investigators. 

The  Tuberculin  Test  of  Pure-bred  Cattle.— Mr.  D.  E.  Salmon,  D.  V.  M., 
Chief  of  the  Bureau  of  Animal  Industry  of  the  United  States  Department 
of  Agriculture,  has  recently  issued  a  pamphlet  in  which  he  demonstrates  the 
necessity  of  guarding  against  the  importation  of  disease  by  means  of  cattle, 
and  upholds  the  present  regulations  to  prevent  such  occurrences  as  proper 
and  consistent.    The  chief  danger  to  cattle  arises  from  the  prevalence  of 


TUBERCULOUS  INTECTION  THROUGH  MILK.  107 

tuberculosis,  which  disease  affects  herds  more  widely  and  more  disastrously 
than  any  other. 

Even  if  the  point  urged  by  Professor  Koch  at  the  British  Congress  on 
Tuberculosis  be  granted,  and  it  is  allowed  that  the  spread  of  tuberculosis  by 
milk  and  meat  is  to  be  feared  but  to  a  slight  extent,  the  fact  must  still  be 
borne  in  mind  that  tuberculosis,  in  itself,  is  a  decimating  factor  among 
cattle  of  immense  importance. 

Mr.  Salmon  shows  that  the  United  States  has  a  very  large  export  trade 
in  cattle,  and  one  that  is  continually  increasing.  He  further  points  out  that 
rigid  restrictions  are  in  force  in  many  countries  in  the  world  to  prevent 
tuberculous  beasts  from  gaining  an  entrance  into  those  territories;  conse- 
quently, if  we  wish  our  cattle  to  enter  those  markets,  they  must  not  only  be 
free  from  tuberculosis  when  they  leave  the  farm,  but  also  when  they  arrive 
in  a  foreign  country.  To  effect  this  object,  every  effort  must  be  put  forth 
to  keep  out  tuberculous  cattle  from  this  country,  for  a  few  thus  diseased  will 
quickly  spread  contagion. 

The  argument  is  therefore  advanced  that  the  tuberculin  test  as  now 
adopted,  must  be  strictly  enforced  to  guard  against  such  a  result.  The  con- 
tention is  likewise  made  that  the  pure-bred  cattle  mainly  imported  from 
Great  Britain  are  the  chief  menace  in  this  respect,  and  that,  if  the  tuber- 
culin test  were  not  strictly  adhered  to,  the  blue-blooded  immigrants  from 
the  United  Kingdom  would  disseminate  the  germs  of  tuberculosis  among 
cattle  from  one  end  of  the  country  to  the  other. 

Tubercle  Bacilli  Disseminated  by  Cows  in  Coughing,  as  a  Possible 
Source  of  Contagion. — The  general  belief  at  the  present  time  that  the  means 
by  which  tuberculosis  is  chiefly  disseminated,  by  the  inhalation  of  dried 
tuberculosis  sputum  which  becomes  pulverized  and  is  carried  about  by  cur- 
rents of  air,  or  put  into  motion  in  other  ways,  has  been  strongly  substan- 
tiated by  numerous  experiments.  Fliigge,  however,  is  not  in  accord  with 
these  views,  and  is  of  the  opinion  that  the  spread .  of  tuberculosis  is  due 
mainly  to  the  inhalation  of  minute  particles  of  sputum  which  the  act  of 
coughing  thus  ejects.  He  further  holds  that  these  particles  float  in  the 
air  for  a  considerable  period  of  time,  and  may  be  blown  hither  and  thither 
by  very  slight  currents.  Klebs,  in  this  country,  has  demonstrated  the  fact 
tbat,  during  the  act  of  coughing,  minute  particles  of  sputum,  often  con- 
taining tubercle  bacilli,  are  thrown  out.  At  his  instance,  too,  Curry,  of 
Boston  {Boston  Medical  and  Surgical  Journal,  October,  1898,  vol.  cxxxix. 
No.  15),  carried  out  a  scries  of  elaborate  experiments  with  the  object  of 
thoroughly  investigating  the  matter. 

Dr.  Curry  concluded  from  his  experiments  that,  although  there  is  a 
possible,  and  even  a  probable,  danger  from  this  source,  Fliigge  has  greatly 
exaggerated  this  danger.  Dr.  iMazyck,  lecturer  and  demonstrator  of  bac~ 
teriology,  Veterinary  Department,  University  of  Pennsylvania,  has  been  led 


108  INFANT  FEEDING. 

to  undertake  experiments  to  see  if  it  were  not  possible  that  cows  in  the  act 
of  coughing  would  likewise  expel  small  particles  of  tuberculous  material 
rich  in  tubercle  bacilli.  The  results  of  these  studies  were  made  the  subject 
of  a  paper  by  Dr.  Mazyck,  which  was  read  before  the  Pathological  Society 
of  Philadelphia  on  November  8,  1900.  The  belief  is  common  that  cows 
when  coughing  swallow  all  their  sputum,  and  do  not  project  it  to  any  extent. 
Dr.  Mazyck,  by  ingenious  methods  devised  by  himself,  has  disproved  this 
theory,  and  has  practically  demonstrated  that,  in  the  act  of  coughing,  cows, 
as  well  as  men,  atomize,  so  to  speak,  their  sputum,  and  project  it  into  the  air 
in  minute  particles,  which  may  float  for  some  time.  Inoculation  of  guinea 
pigs  with  this  secretion  gave  a  considerable  proportion  of  positive  results. 
Dr. -Mazyck  came  to  the  conclusion  that  the  danger  of  infection  by  means 
of  this  atomized  sputum,  as  far  as  mankind  goes,  is  confined  practically  to 
those  in  constant  contact  with  the  animals,  but  for  other  animals  in  the 
same  stable  the  infected  animals  must  be  considered  a  source  of  danger. 
The  moral  to  be  derived  from  the  outcome  of  Dr.  Mazyck's  experiments 
would  seem  to  be  that  when  tuberculosis  is  diagnosed  in  a  cow,  she  should 
be  isolated  as  far  as  is  possible;  at  any  rate,  she  should  not  be  confined  in 
a  shed  with  healthy  animals. 

Sterilization  and  Pasteurization  vs.  Tubercle-free  Herds,  etc.^ — The 
comparative  dependence  upon  sterilization  or  pasteurization  and  the  insur- 
ance of  absolute  absence  of  tubercle  in  herds  supplying  milk  are  discussed 
by  Hope,  who  thinks  that  while  raw  milk  is  especially  liable  to  contamina- 
tion, sterilization,  valuable  as  it  is,  is,  after  all,  only  an  expedient,  and  must 
not  be  put  in  such  prominence  that  the  importance  of  the  other  safeguards 
of  absolute  cleanliness  of  source  and  handling  are  neglected.  Beyond  any 
question,  he  says,  the  ultimate  advantage  lies  in  obtaining  the  milk  from 
herds  free  from  tuberculosis.  A  comparison  is  made  with  having  water 
from  a  contaminated  source  and  making  it  pure  later  by  chemical  processes 
or  boiling  it,  and  obtaining  it  in  the  first  place  from  an  uncontaminated 
source.  He  thinks  it  is  quite  possible  to  insure  that  the  milk  supply  shall 
come  from  cows  free  from  tuberculosis. 

The  State  Veterinarian  of  Pennsylvania,  Dr.  Pearson,  thinks  that  not 
over  2  per  cent,  of  the  cattle  of  that  State  are  tuberculous,  and  probably 
if  a  general  test  of  all  the  cattle  of  the  other  States  mentioned  were  made, 
we  should  find  a  very  much  smaller  proportion  tuberculous  than  is  indicated 
by  this  tabular  statement.  The  explanation  of  the  high  percentages  that 
have  been  given  is  found  in  the  fact  that  it  has  been,  for  the  most  part, 
suspected  herds  which  have  been  tested.  Admitting  that  the  greater  part 
of  these  percentages  are  too  high,  we  still  have  revealed  a  condition  which 
is  worthy  of  our  serious  consideration. 


»E.  W.  Hope  (The  Lancet). 


TUBERCULOUS  ESTFECTION  THROUGH  MILK. 


109 


The  classes  of  animals  most  affected  are  breeding  animals  and  dairy 
stock.  The  beef  cattle  coming  to  our  markets  are  still  singularly  free  from 
tuberculosis.  Of  4,841,166  cattle  slaughtered  in  the  year  1900  under  Fed- 
eral inspection,  but  5279,  or  0.11  per  cent,  were  sufficiently  affected  to  cause 
the  condemnation  of  any  part  of  the'  carcass.  Of  23,336,884  hogs  similarly 
inspected,  5440  were  sufficiently  affected  to  cause  condemnation  of  some  part 
of  the  carcass.  This  is  equal  to  0.023  per  cent.,  or  slightly  more  than  one- 
fifth  the  proportion  found  in  beef  cattle.  It  is  scarcely  necessary  to  add  that 
there  are  certain  lots  of  cattle  and  hogs  encountered  which  are  affected  in 
much  greater  proportion  than  the  general  average  just  given. 

From  a  recent  view  by  Drs.  Eussell  and  Hastings,  of  the  Wisconsin 
Agricultural  Experiment  Station,*  of  the  tests  of  cattle  for  tuberculosis  made 
in  the  United  States,  the  following  summary  is  presented : — 

Table  No.  20. 


Vermont 

Massachusetts  

Massachusetts,  entire  herds      

Connecticut 

New  York,  1894 

New  York,  1897-98 

Pennsylvania 

New  Jersey       

Illinois,  1897-98 

Illinois,  1899 

Michigan 

Minnesota 

Iowa 

Wisconsin — 
Experiment  Station  tests : 

Suspected  herds  

Non-suspected  herds   .       

State  Veterinarian's  tests : 

Suspected  herds  

T&sts  of  local  veterinarians  under  State 
Veterinarian  on  cattle  intended  for 
sliipment  to  States  requiring  tuber- 
culin  certificate       


Number 
Tested. 


60,000 
24,685 

4,093 

6,300 
947 

1,200 

34,000 

22,500 

929 

3,655 

3,430 
873 


323 
935 

588 


3,421 


Number 
Tuberculosis. 


2,390 

12,443 

1,080 

'  66 

163 

4,800 


560 


122 


115 

84 

191 


76 


Per  cent. 
Tuberculosis. 


3.9 
50.0 
26.4 
14.2 

6.9 
18.4 
14.1 
21.4 
12.0 
15..32 
13.0 
11.1 
13.8 


35.6 
9.0 

32.5 


2.2 


The  following  suggestions,  adapted  from  the  fifty  dairy  rules  of  the 
United  States  Department  of  Agriculture,  are  recommended  for  strict  adop- 
tion in  our  dairies: — 

The  Stable. — Keep  dairy  cattle  in  a  room  or  building  by  themselves. 
It  is  preferable,  when  possible,  to  have  no  cellar  below  and  no  storage  loft 
above.  The  stables  should  be  well  ventilated,  lighted,  and  drained;  should 
have  tight  floors  and  walls  and  plainly  constructed.  Store  the  manure  under 
cover  outside  the  cow  stable,  and  remove  it  to  a  distance  as  often  as  prac- 


*  Bulletin  No.  84,  Wisconsin  Agricultural  Experiment  Station,  March,  1901. 


110  INFANT  FEEDING. 

ticable.  Whitewash  the  stables  once  or  twice  a  year;  use  land  plaster  in 
the  manure  gutters  daily.  Clean  and  thoroughly  air  the  stable  before  milk- 
ing; in  hot  weather  sprinkle  the  floor. 

The  Cows. — Have  the  herd  examined  at  least  twice  a  year  by  a  skilled 
veterinarian.  Promptly  remove  from -the  herd  any  animal  suspected  of 
being  in  bad  health  and  reject  her  milk.  Never  add  an  animal  to  the  herd 
imtil  certain  it  is  free  from  disease,  especially  tuberculosis.  Do  not  allow 
the  cows  to  be  excited  by  hard  driving,  abuse,  loud  talking,  or  any  unneces- 
sary disturbance.  Feed  liberally,  and  use  only  fresh,  palatable  food  stuffs. 
Provide  water  in  abundance,  easy  of  access,  and  always  pure.  Do  not  allow 
any  strongly  flavored  food,  like  garlic,  cabbage,  turnips,  to  be  eaten  except 
immediately  after  milking.  Clean  the  entire  body  of  the  cow  daily.  If  the 
hair  in  the  region  of  the  udder  is  not  easily  kept  clean,  it  should  be  clipped. 
If  the  sides  of  the  cow  are  plastered  with  dirt  or  manure,  as  is  often  the 
case,  a  certain  amount  is  sure  to  fall  into  the  pail  of  milk.  This  is  where 
the  trouble  really  begins,  for  this  dirt  and  manure  abound  in  bacteria  which 
cause  decomposition  in  milk,  and  thereby  induce  bowel  disturbances. 

The  Milk. — The  milker  should  be  clean  in  all  respects.  He  should  wash 
and  dry  his  hands  and  clean  his  nails  just  before  milking.  After  the  hands 
have  been  washed,  a  little  vaseline  may  be  used  on  them,  thereby  preventing 
scales  from  the  teat  or  fingers  getting  into  the  milk.  The  milker  should 
wear  clean,  dry  garments,  used  only  when  milking,  and  kept  in  a  clean  place 
at  other  times.  Brush  the  udder  and  surrounding  parts  just  before  milking, 
and  wipe  them  with  a  clean,  damp  cloth  or  sponge.  Commence  milking  at 
the  same  hour  every  morning  and  evening,  and  milk  quietly  and  thoroughly. 
Throw  away  (but  not  on  the  floor — better  in  the  gutter)  the  first  few  streams 
from  each  teat.  This  first  milk  is  watery  and  of  little  value,  and  during 
the  intervals  between  milking,  the  bacteria  from  the  air  get  into  the  cow's 
teats  and  grow  with  great  rapidity.  These  bacteria  cause  early  souring  of  the 
milk.  If  in  any  milking  a  part  of  the  milk  is  bloody  or  stringy  or  un- 
natural in  appearance,  the  whole  mass  should  be  rejected.  Milk  with  dry 
hands,  or  oiled  as  above ;  never  allow  the  hands  to  come  in  contact  with  the 
milk.  If  any  accident  occurs  by  which  the  pail,  full  or  partly  full,  of  milk 
becomes  dirty,  do  not  try  to  remove  this  by  straining,  but  reject  all  this  milk 
and  rinse  the  pail. 

Care  of  the  Milk. — Remove  the  milk  of  every  cow  from  the  dairy  at 
once  to  a  clean,  dry  room,  where  the  air  is  pure  and  sweet.  Do  not  allow 
cans  to  remain  in  stables  while  they  are  being  filled.  Strain  the  milk  through 
a  metal  gauze  and  a  flannel  cloth,  or  layer  of  cotton,  as  soon  as  it  is  drawn. 
Aerate  and  cool  tlie  milk  as  soon  as  strained.  The  rapid  aeration  and  cooling 
of  milk  are  matters  of  great  importance.  Combined  aerators  and  coolers, 
suitable  for  use  with  well  water  or  ice  water,  can  be  had  at  any  diary  supply 
house  at  a  small  cost.    By  using  one  of  these,  the  cow  odor^  the  animal  heat. 


RAW  MILK.  Ill 

and  much  of  the  dirt  can  be  removed  from  milk  in  a  few  minutes.  The  milk 
should  be  cooled  to  45°  F.,  if  for  shipment,  or  to  60°  F.,  if  for  home  use  or 
delivery  to  a  factory.  Never  mix  fresh,  warm  milk  with  that  which  has 
been  cooled.  Do  not  allow  the  milk  to  freeze.  When  cans  are  hauled  a  dis- 
tance they  should  be  full  and  carried  in  a  spring  wagon.  In  hot  weather 
cover  the  cans,  when  moved  in  a  wagon,  with  a  clean,  wet  blanket  or  canvas. 
If  milk  is  stored,  it  should  be  held  in  tanks  of  fresh,  cold  water,  renewed 
daily,  in  a  clean,  cold,  dry  room.  Clean  all  dairy  utensils  by  first  thoroughly 
rinsing  them  in  warm  water;  then  clean  inside  and  out  with  a  brush  and 
hot  water  into  which  a  cleansing  material  is  dissolved ;  then  rinse,  and  lastly 
sterilize  by  boiling  water  or  steam.  Use  pure  water  only.  After  cleaning, 
keep  the  utensils  inverted  in  pure  air  and  sun  if  possible,  until  wanted  for 
use.  Old  cans,  in  which  parts  of  the  tin  are  worn  off,  or  where  there  are 
seams  and  cracks,  are  impossible  to  keep  clean,  and  should  not  be  employed. 

Small  Animals. — Cats  and  dogs  must  not  be  in  the  stables  during  the 
time  of  milking.  The  reason  for  this  is  that  cats  are  peculiarly  liable  to 
transmit  diphtheria;  both  cats  and  dogs  have  disgusting  skin  d'seases  which 
may  be  transmitted  to  children,  and  both  animals  also  are  apt  to  nose  around 
and  dirty  the  utensils. 

If  precautions  like  the  above  are  strictly  carried  out,  the  milk  will  be 
clean  and  remain  fresh  for  a  considerable  length  of  time.  The  fresher  the 
milk  is,  the  better  it  will  be  for  family  use.  The  test  for  un cleanliness  con- 
sists in  an  increase  in  the  proportion  of  lactic  acid  generated  in  the  millc, 
and  in  a  large  increase  in  the  number  of  bacteria  per  cubic  centimeter. 

The  New  York  Senate  passed  a  bill  recentl}^,  forbidding  sale  of  milk 
containing  formaldehyde  or  salicylic  acid,  owing  to  their  injurious  effects  on 
infants. 

Eaw  Milk. 

Monrad  (Jahrbtich  f.  Kinderheilhunde,  No.  55,  p.  61)  describes  a 
series  of  children  fed  with  raw  milk.  These  infants  could  not  digest  ster- 
ilized or  boiled  milk.  Their  condition  improved  when  raw  milk  was  sub- 
stituted. It  was  interesting  to  note  that  during  the  course  of  Monrad's 
investigations  an  infant  received  sterilized  milk  by  mistake,  and  its  former 
dyspeptic  symptoms  reappeared. 

Jensen  found  that  new-born  calves  assimilated  raw  milk,  but  when 
boiled  milk  was  given,  they  were  subject  to  coli-enteritis.  Such  calves  that 
recovered  were  atrophic.  Milk,  when  subjected  to  prolonged  sterilization, 
such  as  tyndalizing  the  milk,  undergoes  certain  chemical  changes.  These 
arc: — 

1.  Nuclein  and  lecithin  are  rendered  insoluble. 

2.  Milk-sugar  is  completely  changed. 

3.  The  coagulability  of  the  casein  is  impaired. 

4.  The  fat  globules  are  separated  and  rise  to  the  surface  of  the  milk. 


112 


rNFANT  FEEDINa. 


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RAW  MILK.  113 

5.  By  the  inJBuence  of  the  chlorides  on  the  casein  peptones  are  formed 
in  the  milk. 

6.  The  milk  is  rendered  unpalatable  by  this  superheating. 

7.  The  albumin  is  rendered  much  less  assimilable  by  prolonged  heating. 
The  increased  number  of  cases  of  rickets  and  Barlow's  disease  since  the 

advent  of  sterilization  do  not  speak  well  for  this  process. 
Certain  factors  should  be  noted : — 

1.  That  sterilization  is  intended  to  kill  pathogenic  bacteria  in  the 
milk. 

2.  That  not  only  are  pathogenic  bacteria  destroyed,  but  also  sapro- 
phytes, which  certainly  have  some  bearing  on  the  digestive  functions  of  an 
infant. 

We  know  that  the  proteolytic  bacteria  are  in  the  milk  for  certain 
reasons : — 

1.  To  coagulate  the  casein, 

2.  To  peptonize  this  coagulated  casein. 

It  is  possible  that  by  sterilizing  milk  and  destroying  these  bacteria,  we 
rob  the  milk  of  microbes  necessary  to  perform  certain  aids  in  the  digestive 
process. 

Such  assistance  in  the  digestion  of  milk  may  not  be  necessary  in  the 
robust  and  normal  infant,  but  it  is  quite  different  when  we  are  dealing  with 
dyspeptic  or  atrophic  infants. 

When  infants  thrive  on  sterilized  milTc,  then  it  is  a  good  plan  to  con- 
tinue the  same;  but  if  dyspeptic  symptoms — vomiting  and  undigested,  cheesy 
stools  with  colicky  symptoms — show  themselves,  then  such  food  should  be 
discontinued.  Such  cases  demand  a  radical  change  of  diet,  and  it  is  here 
that  an  easily  assimilated  form  of  food  is  indicated.    Such  food  is  raw  milk. 

Scorbutic  cases  in  which  we  continue  giving  sterilized  milk  will  not  be 
modified  whether  w^e  add  HCl,  pepsin,  or  alkalies.  The  character  of  the 
food  is  at  fault  and  a  radical  change  must  be  made.  For  the  treatment  of 
atrophy  nothing  will  supersede  raw  milk.  Certain  precautions  must  be  taken 
in  securing  raw  milk  for  infant  feeding. 

The  ideal  cows^  milk  is  clean,  raw  milk.  By  this  is  meant  milk  free 
from  all  possible  contamination.  Such  milk  should  be  obtained  from  a 
stable  having  all  moclern  hygienic  surroundings.  If  greater  attention  were 
bestowed  on  the  condition  of  the  cow,  the  cow's  udder,  the  stable,  the 
bucket,  the  hands  of  the  milker,  then  less  sterilization  and  pasteurization 
would  be  necessary.  Let  it  be  distinctly  understood  that  certain  chemical 
changes  are  brought  about  in  milk  when  it  is  steamed,  be  it  in  the 
process  of  sterilization  or  pasteurization.  Neither  sterilization  nor  pasteur- 
ization adds  to  the  digestibility  of  milk.  Indeed,  chemical  experience  has 
demonstrated  the  fact  that  raw  milk,  sold  in  some  places  as  certified  milk, 
in  the  Walker-Gordon  milk  laborato;:ies  as  guaranteed  milk,  is  more  easily 

• 


114  INFANT  FEEDING. 

assimilated.  It  is  proven  by  the  condition  of  the  stools  as  well  as  the  gas- 
tric digestion. 

Nature  has  given  us  a  good  example  of  how  milk  should  be  fed  to  an 
infant.  Breast-milJc  is  certainly  raw  milk,  and  is  served  to  the  infant  at 
tlie  temperature  of  the  body.  Not  only  does  boiling  and  steaming  of  milk 
produce  chemical  changes  in  the  albuminoids,  but  it  renders  the  process  of 
digestion  much  more  difficult,  and  thus  it  is  that  most  infants  taking  boiled 
milk  suffer  with  constipation.  This  is  not  so,  however,  in  the  case  of  infants 
fed  on  raw  milk. 

When  sterilized  and  pasteurized  milk  are  found  to  disagree  with  chil- 
dren, raw  milk  may  sometimes  be  easily  assimilated.  Thus  it  will  be  found 
that,  while  boiled  milk,  or  sterilized  or  pasteurized  milk,  given  either  whole 
or  with  its  proper  dilution  to  suit  the  various  ages,  will  provoke  constipa- 
tion, by  substituting  raw  milk  for  heated  milk  the  same  will  be  more  easily 
assimilated.  The  author  has  frequently  noted  decided  antiscorbutic  prop- 
erties in  fresh  raw  milk.  In  children  with  pronounced  rickets,  and  even 
scurvy,  the  withdrawal  of  sterilized  or  other  milk  and  the  substituting  of 
fresh  raw  milk  will  work  surprising  changes. 

Biedert^  states  that  he  has  followed  Escherich  and  Epstein,  who  rec- 
ommend giving  full  milk  to  children  at  birth.  In  France,  Budin  and  H. 
de  Eothschild,  and  more  recently  E.  Schlesinger,  in  Germany,  have  given 
undiluted  milk  to  both  sick  and  well  children  as  a  substitute  for  breast- 
milk.  Biedert  claims  to  have  seen  good  results  in  some  instances,  but 
cannot  recommend  whole  milk,  as  a  rule,  for  feeding  children.  Marfan, 
another  advocate  of  pure-milk  feeding,  believes  that  milk  should  be  diluted 
until  the  fourth  or  fifth  month,  but  later  he  advises  pure-milk  feeding. 
Schlesinger,  of  Breslau,  while  giving  pure  milk,  gives  a  longer  interval 
between  the  meals.  That  the  greatest  possible  success  is  not  achieved 
by  this  method  in  France  can  be  judged  by  the  statement  of  Marfan 
while  discussing  the  subject  of  athrepsia.  He  says:  "N'a  jamais  vu 
I'athrepsie  confirmee  se  terminer  favorahlement."  Thus  it  seems  that  even 
we  have  much  better  results  than  the  French,  for  there  are  certainly  a  great 
many  children  who  can  and  will  digest  a  diluted  milk,  and  thin  milk-and- 
cream  mixtures,  as  shown  by  their  stool,  tlieir  sleep,  and  their  increase  in 
weight.  These  same  children  with  enfeebled  digestive  functions  will  in- 
variably show  gastric  disturbances — such  as  vomiting,  colic,  constipation,  or 
diarrhoea,  restlessness,  sleeplessness — and  will  cry  continually  when  given 
wliole  milk.  So  that  whole  niiJlx-f ceding  is  not  aKsimilatod  during  the  early 
iiioiillis  of  a  cliild's  life;  besides  tliev  do  not  increase  in  weight.  This 
nic'thod  of  feeding  has  been  ti'ied  over  and  over  again,  and  we  arc  compelled 
to  discontinue  tiie  heavier  food,  consisting  of  whole  milk,  and  substitute  a 
light  food,  consisting  of  diluted  milk. 


'Fourth  Edition  of  Kindprcrniiliiiiiig.  1!»(K),  i)age  184. 


RAW  MILK.  115 

Fresh  Raw  Milk. — Just  as  the  medical  profession,  and  to  some  extent 
the  laity,  have  become  impressed  with  the  idea  that  milk  should  be  boiled 
before  being  used,  to  insure  the  destruction  of  the  microbe  which  it  contains. 
Dr.  Freudenreich  comes  forward  with  a  series  of  experiments,  by  which 
he  claims  to  prove  that  raw  milk  possesses  remarkable  germicidal  proper- 
ties. According  to  his  experiments,  the  bacillus  of  cholera,  when  put 
into  fresh  cows'  milk,  dies  in  one  hour,  the  bacillus  of  typhoid  fever  suc- 
cumbs at  the  end  of  twenty-four  hours,  while  other  germs  die  at  the  end 
of  varying  periods. 

Milk  which  has  been  exposed  to  a  temperature  of  131"  F.  loses  its 
germicidal  properties.  Milk  which  is  four  or  five  days  old  is  also  devoid. of 
microbe-killing  power,^ 

Undiluted  Milk  as  a  Food  for  Infants. — Notwithstanding  tireless  re- 
search and  wonderful  ingenuity,  a  perfect  substitute  to  replace  mother's 
milk  as  an  article  of  food  for  the  nourishment  of  infants  yet  remains  to  be 
discovered.  This  is  greatly  to  be  regretted,  as  the  occasions  are  not  rare  on 
which  mothers'  milk  is  not  available,  or  it  is  desirable  or  even  necessary 
to  have  recourse  to  such  a  substitute.  The  fact  is  that  there  is  yet  not  a 
little  to  learn  concerning  the  assimilative  processes  in  children,  and  knowl- 
edge, particularly  of  a  practical  character  concerning  food,  is  not  so  exten- 
sive or  so  precise  as  it  might  be.  As  K.  Oppenheimer  points  out  in  a  recent 
communication,  an  article  of  food  for  the  infant  to  serve  as  a  perfect  sub- 
stitute for  mother's  milk  should  be  as  useful  as  the  latter  in  the  nourish- 
ment both  of  healthy  children  and  of  those  suffering  from  gastro-intestinal 
catarrh.  These  requirements,  however,  are  not  met  by  any  of  the  large 
number  of  artificial  foods  that  have  been  devised.  For  the  purpose  of  estab- 
lishing the  usefulness  of  undiluted  cows'  milk  as  judged  by  this  standard, 
Oppenheimer  made  comparative  observations  in  normal  healthy  children, 
in  infants  suffering  from  gastro-intestinal  derangement,  and  in  atrophic 
children.  In  almost  all  of  the  11  cases  of  the  first  group  the  body  weight 
exhibited  a  steady  and  uniform  increase;  while  of  36  cases  of  the  second 
group  only  6  failed  to  do  well;  and  of  12  cases  exhibiting  marked  atropby 
8  failed  to  do  well.  All  of  the  foregoing  cases  were  under  observation  for 
periods  of  more  than  four  weeks.  Of  33  additional  cases  under  observation 
for  a  shorter  period  than  four  weeks,  20  thrived  and  13  did  not. 

The  Dangers. — We  naturally  regard  the  dangers  of  having  tubercle 
bacilli  in  the  milk  as  one  of  the  prime  reasons  for  sterilizing  the  same.  No 
physician  will  use  milk  unless  the  animal  has  been  tested  with  tuberculin. 
We  should  never  employ  the  milk  from  one  cow,  but  always  from  a  mixed 
herd. 


'Bacteriological    World.   December,   1891;    Journal   of   the   American    Medical 
Association,  February  27,  1892.      • 


IIG  INFANT  FEEDING. 

The  danger  of  transmitting  tul)erciil()pis  is  certainly  very  rare.  Au- 
thentic cases  have  been  reported  from  time  to  time  in  medical  literature 
in  which  a  supposed  infection  could  be  attributed  to  milk.  K.  Koch  disputes 
the  possibility  of  transmitting  bovine  tuberculosis  to  man. 

In  a  herd  of  cows  which  has  undergone  the  proper  rctcrinari/  inspection, 
the  danger  of  overseeing  tuhereithsis  of  the  udder  is  reduced  to  a  Diinimum. 
When  the  udder  of  a  cow  has  tubercular  disease,  then,  naturally,  the  danger 
of  infection  exists.  We  must  not  forget  that  there  are  a  great  many  patho- 
genic bacteria  and  their  spores,  which  are  far  more  dangerous  to  the  infant 
than  tubercle  bacilli. 

CiiK-MicAL  Exa:mination  of  Cows'  Milk. 

The  fat  required  for  an  infant  fed  on  cows'  milk  is  about  1  per  cent, 
on  the  second  day  after  birth.  If  the  child  is  normal  we  can  usually  give  it 
2  per  cent,  at  the  end  of  the  first  week ;  3  per  cent,  of  fat  is  usually  sufficient 
for  the  first  month.  Some  children  can  do  well  with  a  feeding  mixture 
containing  this  amount  of  fat  for  the  first  two  months,  while  other  children 
of  the  same  age,  but  with  better  digestive  functions,  can  assimilate  3  per 
cent,  of  fat  at  the  end  of  the  first  month.  During  the  second  month  children 
usually  digest  2  ^/^  per  cent,  of  fat.  At  three  months  we  can  order  3  per 
cent,  if  normal  conditions  exist.  It  must  be  remembered  that  the  average 
cows'  milk  contains  about  4  per  cent,  of  fat,  and  the  writer  does  not  imply 
that  whole  milk  must  necessarily  be  given.  The  guide  for  the  increase  of 
fat  should  always  be  the  "scales."  When  an  infant's  weight  remains  sta- 
tionary then  the  percentage  of  all  ingredients  should  be  increased. 

In  order  to  increase  the  fat  it  is  necesary  to  add  a  definite  quantity  of 
cream.  Three-fifths  of  the  ordinary  cream  consists  of  fat.  To  correct  hard, 
dry  scybala  we  must  increase  the  percentage  of  fat.  A  point  therefore  to 
remember  is,  that  constipation  can  he  modified  to  a  certain  extent  by  the 
addition  of  fat.  Codliver-oil  is  frequently  ordered  as  a  corrective  for  con- 
stipation. It  is  useful  chiefly  for  the  amount  of  fat  that  it  adds  to  the 
food. 

Excess  of  Fat. — Excess  of  fat  is  indicated  by  the  frequent  regurgitation 
of  food  in  small  quantities,  usually  one  or  two  hours  after  feeding.  Some- 
times an  excess  of  fat  causes  very  frequent  passages  nearly  normal  in 
appearance.  In  some  cases  the  stools  contain  small,  round  lumps  somewhat 
resembling  casein,  but  really  masses  of  fat.  This  has  already  been  men- 
tioned in  speaking  of  the  differentiation  of  true  casein  curds  and  small,  fat 
lumps  by  the  solubility  of  the  latter  in  alcohol  or  ether. 

Fat  Diarrhcea. — Biedert  and  Demme  have  devoted  considerable  atten- 
tion to  this  subject.  (See  Biedert:  "Fett-Diarrhae,"  in  "Jahrhuch  fiir  Kin- 
derheilkunde,"  1878).     In  some  children  the  faeces  showed  50  to  GO  per 


*Read  also  chapter  on  "Cream.'* 


FAT.  117 

cent,  of  fat,  whereas  the  normal  percentage  in  ordinary  fa?ces  varied  from 
13.9  per  cent,  (which  is  the  normal  quantity)  according  to  Uffelmann. 

Babcock's  Milk  Test. — In  this  country  the  so-called  Babcock  Milk  Test, 
invented  by  Dr.  S.  M.  Babcock,  has  been  adopted  in  preference  to  other 
practical  milk  tests,  in  creameries  and  cheese  factories  as  well  as  in  milk 
laboratories.  The  cause  of  the  general  adoption  of  this  test  is  doubtless 
to  be  foimd  in  its  simplicity,  cheapness,  and  ease  of  manipulation.  Briefly 
stated,  the  test  is  operated  as  follows :  17.6  cubic  centimeters  of  milk  is 
measured  into  a  special  milk-test  bottle,  an  equal  quantity  of  commercial 
HoSO^  (specific  gravity,  about  1.83)  is  added,  and  after  mixing  the  two 
liquids,  the  test  bottle  is  placed  in  a  centrifugal  machine  and  whirled  for 
four  minutes;  hot  water  is  then  added  to  the  bottle  to  bring  the  fat  into 
graduated  narrow  neck  of  the  bottle,  and  after  a  second  whirling  of  one 
minute,  the  per  cent,  of  fat  in  the  milk  is  read  off  from  the  scale  of  the 
test  bottle. 


Fig.  37. — Centrifugal  Testing  Machine,  for  Ilandpower. 

A  determination  of  fat  in  milk  by  this  method  takes  less  than  fifteen 
minutes,  and  when  care  is  taken  in  sampling  the  milk  and  reading  of  the 
result,  is  accurate  to  within  one-tenth  of  1  per  cent.  Babcock  testers  are 
now  placed  on  the  market  by  many  manufacturers  of  dairy  supplies  and  at 
a  remarkably  low  price,  thanks  to  sharp  competition  among  the  manufac- 
turers. The  testers  are  either  hand  or  power  (steam  or  motor)  machines 
and  built  to  hold  from  two  to  thirty  or  more  test  bottles  at  a  time.  The 
number  of  revolutions  at  which  they  must  be  run  ranges  from  800  to  1200 
per  minute,  according  to  the  diameter  of  the  testers. 

The  Determination  of  Fat. — The  simplest  method  is  by  the  cream  gauge 
(Fig.  38).  Aitliough  its  results  are  only  approximate,  they  are  in  most 
cases  sufficiently  accurate  for  clinical  purposes.  The  tube  is  filled  to  the 
zero  mark  with  freshly  drawn  milk,  which  stands  at  a  room  temperature  for 
twenty-four  liours,  when  the  percentage  of  cream  is  read  off.  The  ratio  of 
cream  to  fat  is  approximately  5  to  3,  thus  T)  i)er  cent,  cream  represents  3 
per  cent,  fat,  etc. 

.vnolhcr  rapid  method  is  by  ]\rarchand's  tube. 

Marchand's  Test. — First  i)ut  into  the  tube  five  cubic  centimeters  of 
milk,  up  to  the  line  M;  then  four  or  five  drops  of  liquor  sodte;  shake;  add 


118 


INFANT  FEEDING. 


five  cubic  centimeters  of  ether,  up  to  the  line  E.  Cork,  and  shake  fifteen 
or  twenty  times;  add  90  per  cent,  alcohol,  up  to  the  line  A.  The  tube  is 
now  tightly  corked,  shaken  thoroughly,  and  placed  upright  in  a  tall  bottle 
containing  water  at  a  temperature  of  120°  to  150°  F.  The  fat  separates  and 
forms  a  distinct  layer  at  the  top,  and  after  half  an  hour  the  amount  is  read 
off  in  degrees.  By  reference  to  the  following  table  the  exact  percentage  of 
fat  is  shown  : — 

Table  No.  22. 


Degrees,  Marchand. 

Percentage  of  Fat. 

Degrees,  Marchand. 

Percentage  of  Fat. 

1 

1.49 

13 

4.29 

3 

1.96 

15 

4.75 

5 

2.42 

17 

5  22 

7 

2.89 

19 

5.(J8 

9 

3.36 

21 

6.14 

11 

3.82 

Fig.  38.— Graduated  Cream 
Gauge,  10x134 


n 


ClS 


cj^ 


u 

Fig.  3ii.— March:ind's  Tiil>e. 


■I^.l 


It'  -lij 


Fig.  40.— Feser's  I.actoscoi)e. 


Each  additional  degree  on  the  tube  corresponds  to  0.23  per  cent,  of  fat. 
To  insure  accuracy  the  test  should  be  repeated  two  or  three  times  with  the 
same  specimen.^ 

Another  test  is  made  by  the  use  of  Feser's  Lactoscope.  (See  Fig.  40.) 
The  test  is  made  as  follows:  Four  cubic  centimeters  of  milk  are  measured 
off  in  a  pipet,  put  into  a  tube,  and  water  slowly  added,  shaking  from  time  to 
time  until  the  black  lines  of  the  porcelain  stem  at  A  are  clearly  visible 


^ These  tubes  may  be  obtained  from  E.  Gicimr,  51  William  Street,  New  York. 


MILK  SUGAR  OR  LACTOSE.  119 

through  the  mixture  of  milk  and  water.  The  percentage  of  fat  is  then  read 
off  on  the  glass  cylinder  at  the  level  of  the  water  added ;  thus,  if  the  water 
is  to  the  mark  4,  it  indicates  the  presence  of  4  per  cent,  of  fat.  This  tesif 
is  only  applicable  to  cows'  milk. 

It  seems  to  be  pretty  well  settled  that  the  fat  in  woman's  milk  usually 
varies  between  3  and  5  per  cent.,  the  sugar  between  4  and  8  per  cent., 
proteids    (albumin  and  casein)   between   1   and   2  per  cent.,  and  the  ash 


Fig.  41. — Cows'  Milk,  Showing  Fat-globules,  Magnified  330  Diameters. 

between  0.2  and  0.4  per  cent.,  the  water  being  about  88  per  cent.  Wide 
extremes  are  met  with;  so  it  is  useless  to  think  of  woman's  milk  as  of  a 
certain  composition. 

Milk  Sugar  or  Lactose. 

Milk  sugar  being  normally  found  in  brcast-niilk  has  been  advocated  by 
very  many  writers.  Soxhlet  and  Eeubner  in  Europe;  Holt  and  Eotch,  in 
America,  advocate  the  use  of  milk  sugar  in  infant-feeding.  Jacobi  and 
Fischer,^  among  others,  prefer  cane  sugar. 

Cane  Sugar. — Cane  sugar  has  been  employed  in  commerce  as  a  means 
of  preserving  food  and  milk.     It  certainly  possesses  antibactericidal  prop- 


'  See  Infant  Feeding.     Louis  Fischer.     Tliird  Edition,  page  139. 


120 


INFANT  FEEDING. 


erties.  Brush  made  a  series  of  experiments  with  the  milk  sugar  of  commerce, 
and  found  that  the  urine  of  babies  fed  on  milk  to  which  milk  sugar  was 
added,  invariably  excreted  the  sugar  by  the  kidneys  and  bowels.  The  urine 
of  such  infants  contained  sugar  when  examined  by  Fehling's  Test.  It  is 
interesting  to  note  that  babies  fed  on  milk  mixture  containing  milk  sugar, 
always  give  a  sugar  reaction  in  the  urine. 

Bernard  has  shown  that  7  grains  of  milk  sugar  dissolved  in  1  ounce 
of  water,  could  be  injected  under  the  skin  of  a  rabbit  without  giving  a  reac- 
tion of  sugar  in  the  urine. 

The  reverse  was  true  when  cane  sugar  was  tried.  Hence  the  conclusions 
are  the  exact  opposite  of  those  given  by  Brush.  The  urine  of  breast-fed 
babies  did  not,  when  examined,  give  a  positive  reaction.  Thus  it  proves  that 
milk  sugar  in  the  human  breast-milk,  when  given  to  an  infant,  is  readily 
assimilated,  whereas  milk  sugar  of  commerce  is  only  partly  assimilated  and 
partly  excreted. 

Table  No.  23. 


Comparative  Average. 

Woman's  Milk. 
Per  Cent. 

Cows'  Milk. 
Per  Cent. 

Fat        

Proteids 

4.00 
1.50 
7.00 
0  20 
87.30 

3.50 
4.00 

Snorar         .    .              .             ... 

4  30 

Salts 

0.70 

Water 

87.50 

• 

100.00 

100.00 

Albert  E.  Leeds^  states  that  all  the  samples  of  powdered  milk  sugar 
coming  from  drug  stores,  examined  by  him,  were  contaminated.  When 
the  sugar  was  dissolved  in  sterile  water  and  a  gelatine  peptone  culture  was 
made,  bacteria  invariably  were  found.  Hence  the  conclusion  that  milk 
sugar,  as  it  is  commonly  found  in  the  shops,  is  not  safe  for  infant-feeding. 

The  nutrient  value  of  sugar  is  certainly  overestimated.  We  know, 
according  to  chemists,  that  carnivorous  animals  do  not  secrete  sugar  to  any 
appreciable  extent.  That  sugar  is  not  a  necessary  element  of  food  can  be 
seen  by  the  fact  that  canines  secrete  no  sugar  in  their  milk,  and  still  a  small 
slut  can  nurse  seven  or  eight  puppies  and  keep  them  all  fat.  Condensed 
milk  is  certainly  made  up  chiefly  of  sugar.  We  all  know  that  infants  reared 
on  this  food  have  rickets  more  readily  and  succumb  to  gastro-intestinal  and 
infectious  disorders  more  easily  than  infants  on  any  other  form  of  feeding. 

Escherich  states  that  the  bacillus  lactis  aerogenes  is  normally  present 
during  digestion.  It  acts  on  the  milk  sugar  to  produce  an  organic  acid 
which  drives  out  the  more  noxious  forms  of  bacteria,  which  by  their  pres- 
ence would  interfere  with  normal  digestion. 


*  Journal  of  American  Chemical  Society. 


PROTEIDS.  121 

When  milk  sugar  is  converted  into  glucose  and  galactose,  we  physio- 
logically have  a  gradual  conversion  into  lactic  acid,  which  may  aid  in  the 
digestion  of  the  proteids,  thus  giving  us  a  very  valuable  addition  to  the 
means  at  our  command  for  rendering  modified  cows'  milk  digestible  (Eotch). 

Sugar  is  too  Low. — If  the  sugar  is  too  low  the  gain  in  weight  is  apt 
to  be  slower  than  when  furnished  in  proper  amount. 

Sugar  in  Excess. — Symptoms  indicating  an  excess  of  sugar:  Colic  or 
thin  green  very  acid  stools,  sometimes  causing  irritation  of  the  buttocks; 
sometimes  there  is  regurgitation  of  food  and  eructations  of  gas. 

The  Proteids.^ 

The  proteids  are  one  of  the  most,  if  not  the  most,  important  constit- 
uents of  milk.  Deficiency  of  proteids  means  retarded  development.  The 
proteids  have  always  been  regarded  as  the  backbone  of  food.  They  have  a 
group  of  closely  related  substances  which  are  perhaps  modifications  of  the 
same  body.    The  proteids  are  the  albuminous  compounds. 

According  to  Pavy  the  nitrogenous  compounds  are  mainly  'Tiistogen- 
etic"  or  tissue-forming  material.  By  the  separation  of  urea  which  occurs 
in  this  metamorphosis  in  the  animal  system,  a  hydrocarbonaceous  compound 
is  left  which  may  be  appropriated  to  heat  production. 

When  we  examine  the  proteids  of  human  milk,  we  find  that  the  anal- 
3^sis  shows: — 

Table  No.  24. 

Human  Milk.  Cows'  Milk. 

Caseinogen ...  Small  Amount  Caseinogen. .  .Large  Amount 

Lactalbumin . .Large  Amount  Lactalbumin.. Small  Amount 

In  human  milh  Konig  finds  the  lactalbumin  is  about  two-thirds  (Vs) 
and  the  caseinogen  about  one-third  (^/g)  of  the  total  proteids.  In  cows' 
milk  the  lactalbumin  is  only  one-sixth  (Ve)  to  five-sixths  (^/g)  caseinogen. 
Eotch,  reasoning  from  this  standpoint,  advises,  in  writing  a  prescrip- 
tion which  calls  for  a  total  proteid  of  1  per  cent.,  that  we  should  calculate 
to  have  0.75  per  cent,  lactalbumin  and  0.25  per  cent,  caseinogen. 

A  prescription  calling  for  fat,  3  per  cent.;  sugar,  6  per  cent.;  proteid, 
1  per  cent.;   alkalinity,  5  per  cent.,  would  be  written  as  follows: — 

Per  Cent. 

IJ  Fat    3.00 

Sugar 6.00 

Proteids   (total)   LOO 

(c)   Lactalbumin    0.75 

(6)   Caseinogen    0.25 

Number  of  feedings  9 

Amount  at  each  feeding  75  c.c.   (52  V») 

Infant's  age   3  weeks 

Infant's  weight   9  pounds 

Alkalinity    ; 5  per  cent. 

Heat  at 155°  F. 

'!^ce  also  article  l.alinratoi  y  MiiiliCicatioii,  paye  ITU. 


122  INFANT  FEEDING. 

It  is  to  be  noted  that  although  the  total  proteid  percentage  in  the  milk 
for  an  infant  may  be  considerably  increased,  it  is  these  higher  percentages 
which  are  the  most  irrational  in  their  nutritive  values  in  the  early  months 
of  infancy,  if  we  hold  to  the  rule  that  the  caseinogen  should  be  only  one-third 
of  the  total  proteids.  This  ratio  of  lactalbumin  to  caseinogen  can  be  ob- 
tained if  we  are  writing  for  a  low  proteid,  as  in  the  above  prescription,  or 
in  a  prescription  calling  for  a  total  proteid  percentage  of  0.75,  of  which 
0.25  per  cent,  shall  be  caseinogen  and  0.50  per  cent,  lactalbumin.  If,  on 
the  other  hand,  we  write  for  a  high  total  proteid,  such  as  3  per  cent.,  the 
highest  percentage  of  lactalbumin  that  can  be  obtained  is  0.85,  and  the 
remaining  2.15  per  cent,  is  caseinogen,  which  practically  reverses  our  ratio, 
making  the  caseinogen  over  two-thirds  (Vs)?  ^i^cl  the  lactalbumin  less  than 
one-third  (V3). 

It  can  be  said,  however,  that  as  the  infant  grows  older  its  power  to 
digest  casein  becomes  proportionately  greater,  so  that  in  the  later  months 
of  infancy,  the  tenth,  eleventh,  and  twelfth,  its  proteolytic  function  has 
become  adapted  to  this  change  in  the  ratio  of  the  caseinogen  and  lactalbumin, 
so  that  the  higher  total  proteids,  such  as  2.50,  3,  3.50,  and  finally  4  per 
cent.,  with  the  relatively  high  caseinogen  and  low  lactalbumin,  become  the 
proper  nutritive  portion  for  the  infant. 

The  point  especially  to  be  emphasized  is  that  in  the  early  months  of 
life,  which  demand  a  low  proteid  percentage,  we  can  by  the  use  of  whey 
obtain,  in  a  modified  milk,  the  same  proportions  of  lactalbumin  and  case- 
inogen which  we  find  in  human  breast-milk  at  a  corresponding  period  of 
infancy. 

Split  Proteids  in  Infant  Feeding. — Little  is  known  either  here  or 
abroad  of  the  physiologic  difi'erence  between  the  proteids  of  cows'  milk  and 
of  human  milk.  It  is  of  great  advantage  to  be  able  to  approximate  the 
proportion  of  whey  proteid  to  caseinogen  in  preparing  artificial  foods. 

In  an  address  before  the  British  Medical  Association  {Br.  Med.  Jour., 
Sept.  6,  1902)  Eotch  said  that  this  use  of  the  split  proteids,  which  has  been 
introduced  largely  through  the  experiments  of  White  and  Ladd,  was  prob- 
ably the  most  important  step  in  advance  taken  in  recent  times. 

Their  conclusions  were  as  follows : — 

1.  By  the  use  of  whey  as  a  diluent  of  creams  of  various  strengths,  cows* 
milk  can  be  modified  so  that  its  proportions  of  caseinogen  and  whey  proteids 
closely  correspond  to  those  in  human  milk. 

2.  The  whey  must  not  be  heated  above  G9.3°  C.  or  its  proteids  coagu- 
late;  65.5°  C.  destroys  the  rennin  enzyme. 

3.  The  emulsions  of  fat  in  whey,  barley  water,  gravity  cream,  and  cen- 
trifugal cream  mixtures  were  the  same ;  and  though  the  combination  of  heat 
and  transportation  may  destroy  the  emulsion  in  any  modified  milk,  this  may 
surely  be  prevented  by  keeping  the  milk  cool  during  delivery. 


METHOD  OF  ESTIMATING  PROTEIDS.  123 

4.  Whey-cream  mixtures  yield  a  much  finer,  less  bulky,  and  more 
digestible  coagulum  than  plain  modified  mixtures  with  the  same  total  pro- 
teids.  It  is  clear  that  the  use  of  barley  water,  which  gives  the  next  finer 
coagulum,  is  not  indicated.  The  tenacity  of  the  whey  coagulum  is  not 
influenced  by  the  proportion  of  fat  present,  and  whey,  while  not  so  impor- 
tant in  its  mechanical  action  in  affecting  the  coagulum  as  the  cereal  diluents, 
still  had  a  pronounced  power  in  that  direction.  In  very  young  infants  the 
total  proteid  should  be  above  0.75.  Of  this  0.50  should  be  whey  albumin  and 
0.25  caseinogen.  "When  the  infant  has  reached  an  age  where  it  requires  a 
higher  total  proteid  than  1.75,  on  account  of  lack  of  chemical  knowledge, 
we  must  begin  to  give  whole  proteid. 

Proteids  in  Excess. — Proteids  in  excess  are  indicated. by  the  presence 
of  curds  in  the  stools.  This  is  the  most  frequent  cause  of  colic  in  infants. 
Sometimes  there  is  diarrhoea,  more  often  constipation  when  the  proteids  are 
in  excess.  This  excess  of  proteids  frequently  causes  vomiting,  and  so  does 
an  excess  of  both  fat  or  sugar.  If,  therefore,  after  reducing  the  percentage 
of  proteids,  fat,  and  sugar,  vomiting  still  persists,  then  we  must  feed  the  baby 
with  smaller  quantities.  Thus  we  may  have  to  give  a  4-ounce  bottle  where 
a  6-ounce  or  a  5-ounce  feeding  causes  vomiting.  Certain  rules  can  be  laid 
down;  if  an  infant  does  not  thrive,  i.e.,  does  not  gain  in  weight  without 
showing  any  signs  of  indigestion,  then  the  proportions,  i.e.,  percentages  of 
all  ingredients,  should  be  gradually  increased,  chiefly  the  proteids,  however, 
for  the  latter  is  the  most  important  element  in  an  infant's  food. 

A  Clinical  Method  for  the  Estimation  of  Breast-milk  Proteids.^ — "Two 
'milk-burettes,'  each  containing  5  cubic  centimeters  of  milk,  are  subjected  to 
a  temperature  warm  enough  to  rapidly  sour  the  milk,  and  are  allowed  to 
remain  in  this  warmth  until  a  distinct  precipitation  can  be  seen.  The 
burettes  are  then  cooled  in  water,  the  milk-serum  is  withdrawn  into  the 
graduated  tubes,  10  cubic  centimeters  of  Esbach's  solution  (picric  acid,  5 
grams;  citric  acid,  10  grams;  water,  500  cubic  centimeters)  are  added,  the 
tubes  are  shaken,  and  centrifugated  until  constant  reading,  and  the  resulting 
precipitate  is  read.  This  reading  expresses  in  percentage  the  total  amount 
of  proteids  in  the  milk. 

''Such  is  a  bare  statement  of  the  method.  I  will  briefly  take  up  the 
various  steps  in  detail.  The  'Milk-burettes'  are  made  of  about  10  cubic 
centimeters'  capacity,  and  have  a  glass  pinch-cock  or  valve  and  a  narrow 
exit-tube  about  an  inch  long  (Fig.  42). 

"I  have  tried  various  forms  of  burettes  and  separating  funnels,  and 
find  this  the  most  sat'sfactory.  A  temperature  of  from  95°  to  100°  F.  is 
the  most  rapidly  effective  to  produce  fermentation.  This  I  have  most  con- 
veniently obtained  by  placing  the  tubes  in  a  burette-stand,  and  the  stand  in 


*  Reprinted  in  large  part  from  George  Woodward's  article  in  the  Phila.  Med. 
Journal,  May  21,  1898. 


124 


INFANT  FEEDING. 


contact  with  a  radiator.  The  time  required  to  obtain  a  distinct  precipitation 
of  casein  is  from  eighteen  to  twenty-four  hours.  At  the  end  of  this  time 
the  milk  has  distinctly  separated  into  an  upper  layer  of  viscid  yellow  fat; 
a  lower  layer  of  fluid  milk,  quite  opaque  above,  almost  translucent  below, 
and  clinging  to  the  sides  of  the  tube,  and  especially  at  the  bottom,  a  granular 
precipitate.  The  cooling  of  the  milk  increases  the  viscidity  of  the  fat  and 
facilitates  its  separation  from  the  milk-serum.  The  milk-serum  is  received 
into  15-cubic-centimeter  graduated  tubes,  the  solution  of  picric  acid  and 
citric  acid  added  up  to  the  15-cubic-centimeter  mark,  the  mixture  stirred 
with  a  glass  rod  and  placed  in  the  hand-centrifuge.    The  amount  of  cen- 

trifugation  required  is  in  direct  proportion 
to  the  care  used  in  separating  the  fat.  If 
fermentation  be  watched  and  the  separation 
be  made  as  soon  as  the  casein-precipitate  is 
distinctly  present,  the  centrifugation  to  a 
constant  reading  may  be  quickly  accom- 
plished." 

"According  to  Schlossman,  of  the  all)n- 
minoids  in  woman's  milk,  63  per  cent,  are 
casein,  37  per  cent,  lacto-albumin,  the  latter 
of  which  is  absorbed  directly.  There  is, 
moreover,  according  to  Wroblewski,  in  the 
human  milk  another  proteid  rich  in  sulj^hur, 
poor  in  carbohydrate,  and  according  to  some, 
albumoses  and  peptones,  that  also  would  be 
directly  absorbable. 

Of  nucleon  (v.  Wittmaack  and  M.  Sieg- 
fried, Zeitsch.  f.  phys.  C*hem.  xxii),  there  is 
contained  in  cow's  milk  0.057,  in  goat's  milk 
0.110,  and  in  woman's  0.134  per  cent.  In 
cow's  milk  the  phos])horus  of  the  nucleon 
amounts  to  (i  per  cent,  of  the  total  amount  of  phosphorus  contained  in  the 
milk,  in  woman's  milk  41.5  per  cent.  That  explains  why  good  cow's  milk 
with  its  inorganic  phosphates  may  give  a  baby  rachitis,  while  good  breast 
milk  does  not  do  so  at  all."     (A.  Jacobi,  Pediatrics,  Nov.  1,  1900). 

Curdling  of.  Milk  and  Diluents. — Milk  of  all  animals  may  be  separated 
into  two  classes,  those  that  form  a  soft  curd  with  rennet  and  those  that 
form  a  hard  curd  with  rennet.  Woman's  milk  is  in  the  first  class  and  cows' 
milk  in  the  second. 

The  conditions  favorable  for  the  formation  of  hard  curds  of  cows'  milk 
are  body  heat  and  the  presence  of  rennet  and  lactic  or  other  acid. 

The  rennet  forms  a  clot  of  the  milk,  the  heat  causes  the  lactic  bacteria 
to  grow  in  the  curd,  and  the  acid  causes  the  curd  to  shrink  and  become  leath- 


V'lg.  42. — Woodward's  Burette 
for  Estimatins:  Proteids. 


ALBURnNOlDS  IN  COWS'  MILK.  125 

ery.    Adding  alkalies  to  the  milk  neutralizes  the  acid,  but  the  bacteria  will 
keep  making  more  lactic  acid  as  long  as  any  sugar  is  present. 

Diluting  milk  with  water  does  not  prevent  tough  curds  forming,  but 
diluting  with  gruels  does  prevent  the  contraction  of  the  curds.  This  has 
been  proved  beyond  dispute,  both  experimentally  and  clinically. 

Albuminoids  in  Cows'  Milk. 

That  there  are  differences  in  the  amounts  of  the  albuminoids  occurring 
in  human  milk  is  proven  by  the  fact  that,  while  Professor  Leeds  found  a 
variation  of  0.85  to  4.86,  Professor  Meiggs  asserts  that  there  was  but  1  per 
cent. 

Konig,  an  earlier  analyst,  makes  the  variation  from  0.85  to  4.86.  Some 
of  these  results  give  as  high  a  percentage  of  albuminoids  in  woman's  milk 
as  we  find  in  cows'  milk,  and  I  have  no  doubt  in  my  own  mind  that  the  time 
and  habit  of  extracting  the  milk  has  a  deal  to  do  with  the  amount  of  occur- 
ring albumJnoids.  In  other  words,  when  milk  is  extracted  every  two  hours 
or  less,  it  cannot  contain  as  much  of  the  cell-material  as  milk  from  the  same 
source  extracted  at  intervals  of  twelve  hours.  This  latter  is  riper  and  it  is 
the  non-conformity  of  the  tissue  which  causes  all  the  difference  in  the  dif- 
ferent occurring  albuminoids.  We  know  that  during  the  incubation  of  eggs 
casein  is  developed  from  egg-albumin.  This  illustrates  the  ripening  of  albu- 
min. Furthermore,  take  an  egg  just  laid  by  the  hen,  and  boil  it,  and  you 
will  find  immature  albumin  in  it;  that  is,  after  boiling,  instead  of  being 
thick  and  firm,  like  an  older  egg,  much  of  it  is  milky.  If  boiled  a  few  hours 
later,  all  the  albumin  will  coagulate  perfectly,  because  it  has  had  time  to 
ripen.  There  is  no  doubt  that  the  albuminoids  in  milk  from  healthy  animals 
are  all  cell-transformations,  not  an  exudate,  as  are  undoubtedly  the  fats  and 
salts,  because  these  latter  we  can  influence  by  the  food  very  plainly,  but  in 
health  the  albuminoids  are  constant  without  regard  to  food,  wh'le  during 
menstruation,  pregnancy,  and  other  conditions,  notably  febrile  disturbances, 
we  find  the  fats  and  salts  not  materially  affected,  but  the  albuminoids  de- 
creased, increased,  or  totally  changed,  as  in  the  case  of  colostrum.  The 
casein,  besides  being  riper  in  cows'  milk,  by  reason  of  its  stronger  growth, 
is  intended  by  Nature  to  coagulate  into  a  hard  mass,  because  it  is  the  product 
of  a  cud-chewer  for  the  nourishment  of  a  cud-chewer,  and  the  reason  why 
it  does  not  always  coagulate  in  the  infant's  stomach  as  it  docs  in  that  of 
the  calf  is  that  the  latter  animal's  stomach  secretes  a  principle  called  chy- 
mosinj  this  is  the  principle  that  curdles  cows'  milk,  and  it  operates  either 
in  au  acid  or  an  alkaline  medium.  Pepsin  will  not  coagulate  milk,  and 
hence  the  hard  coagulum  of  cows'  milk  that  sometimes  forms  in  the  infant's 
stomach  is  due  to  acidity  of  that  organ,  and  this  acidity  is  not  always  the 
fault  of  the  stomach,  but  of  the  milk  itself.  The  variations  in  the  chemistry 
of  the  albuminoids  found  in  cows'  milk  would  not  be  surprising  to  anyone 


126  INFANT  FEEDING. 

if  he  would  examine  into  the  condition  of  some  of  its  mammary  sources. 
Thus  it  will  often  be  found,  on  dissecting  a  cow's  udder,  that  there  are  old 
cicatrices,  one  or  more  quarters  of  the  udder  intensely  inflamed,  sometimes 
a  mammiferous  duct  clogged  with  a  calculus  or  a  clot  of  fibrin.  Besides 
these  pathological  conditions,  the  mammary  gland  is  subject  to  benign  and 
malign  infiltrations,  bacillary  tubercular  deposits,  and  eruptive  diseases  of 
the  skin  involving  the  gland  and  ducts.  Therefore,  that  fibrin,  serum,  and 
albumin,  in  various  forms,  are  found  in  the  cows'  milk  is  not  surprising,  and 
it  can  safely  be  assumed  that  any  variation  in  the  albuminoids  from  the 
normal  casein  can  be  ascribed  to  sickness  on  the  part  of  the  animal. 

Salts. 

We  next  come  to  the  salts  contained  in  milk,  and  it  is  remarkable  how 
few  analyses  have  been  made  to  determine  the  salts  or  minerals  that  are 
contained  in  this  fluid.  Heidlen's  analysis,  copied  everywhere,  seems  to  be 
the  only  exhaustive  one  of  the  salines  in  cows'  milk  made  during  the  past 
century.  It  seems  to  me  in  this  case,  too,  that  it  is  time  for  the  chemist  to 
teach  us  something  more.  "There  probably  never  was  a  time,  in  our  era,  at 
least,  when  milk  was  attracting  so  much  attention  as  now,  and  still  all  our 
chemists  are  content  with  the  total  solids,  fats,  albuminoids,  and  sugar — just 
what  the  butter-makers  and  cheese-makers  want  to  know.  From  this  much- 
quoted  analysis  of  cows'-milk  salts  we  learn  that  milk  contains  in  various 
proportions  the  phosphates  of  lime,  magnesia,  and  iron;  the  chlorides  of 
potassium,  sodium,  and  iron;  and  free  soda.  Eobin  gets  from  human  milk, 
in  addition  to  the  foregoing,  carbonate  of  lime  and  soda,  phosphate  of  soda, 
sulphate  of  soda,  and  potash.  We  have  no  means  of  knowing  how  constant 
is  the  occurrence  of  any  of  these  salts  in  milk  or  under  what  conditions  they 
are  modified;  we  do  know,  however,  from  the  experiments  of  Fehling,  that 
many  of  the  drugs  administered  to  the  milking  female  are  excreted  in  the 
milk.  Therefore,  we  can  safely  assume  that  the  saline  constituents  occurring 
in  milk  are  infiuenced  both  by  the  health  and  food  of  the  animal.  That  the 
phosphates  are  craved  for  by  the  milking  cow  is  evidenced  by  the  habit  of 
chewing  old  bones  and  the  like,  and  that  there  is  a  lack  of  this  element  of 
food  is  not  to  he  wondered  at  when  we  see  herds  of  milking  cows  pastured 
on  old,  worn-out  lands.  The  practical  farmer  knows  that  exhausted  pasture- 
lands  need,  more  than  anything  else  for  their  rejuvenescence,  the  phosphates, 
and  we  know  that  in  our  nutrition  we  need  them  also.  The  land  on  which  a 
cow  is  pastured  will  indicate  pretty  fairly  what  we  may  expect  to  find  in 
her  milk  as  salts.  We  have  all  noticed  the  excessive  growth  of  sorrel  on 
exhausted  land.  Can  it  then  be  a  subject  of  wonder  that  some  kind  of  a 
vegetable  acid  should  be  found  in  the  milk  of  animals  that  are  obliged  to 
include  this  variety  of  food  in  their  summer-rations  and  sour  ensilage  or 
spoiled  brewery  grains  in  their  winter-feed?    Theodore  Hankel's  discovery 


SALTS.  ENZYMES.  STARCH.  127 

of  citric  acid  in  cows'  milk  to  the  amount  of  0.9  and  1.1  grams  per  liter  is 
just  what  might  be  expected." 

Lime-salts  in  Cows'  Milk. — -Milk  curdles  under  two  entirely  distinct 
sets  of  conditions:  (1)  it  curdles  on  addition  of  an  acid,  and  (2)  it  curdles 
under  the  influence  of  rennet  (when  the  reaction  of  the  milk  is  either  neutral 
or  slightly  acid).  The  two  varieties  of  curds  which  may  be  obtained  under 
these  circumstances  may  be  denominated  "acid  curds"  and  "rennet  curds/' 
respectively.  Acid  curds  must  inevitably  be  formed  in  the  stomach  after 
milk  has  been  drunk,  if  the  gastric  contents  are  allowed  to  become  acid. 
Such  curds  (we  are  familiar  with  them  in  ordinary  life  in  the  form,  for 
instance,  of  cream-cheese  or  sour-milk)  are  probably  not  sufficiently  firm  to 
set  up  digestive  disturbances.  On  the  other  hand,  rennet  curds  (such  as  we 
are  familiar  with  in  the  form  of  renneted  milk  and  of  ordinary  cheese)  may 
be  extremely  firm.  It  is,  therefore,  in  all  prohability  these  rennet  curds 
which  set  up  the  familiar  infantile  dyspepsia  of  hottle-fed  children.  If  this 
is  so,  the  facts  elicited  by  Arthus  and  Pages  would  appear  to  be  of  dominat- 
ing importance  in  the  treatment  of  these  dyspeptic  conditions.  In  order  to 
appreciate  this  correctly  the  following  facts  must  be  attended  to :  ( 1 ) 
rennet-coagulat:on  is  delayed  and  curdling  becomes  less  and  less  firm  as  an 
increasing  proportion  of  the  lime-salts  of  the  milk  becomes  precipitated  as 
insoluble  salts;  (2)  addition  of  soluble  lime-salts  (up  to  a  certain  maxi- 
mum) causes  increased  rapidity  of  rennet-coagulation,  accompanied  by  in- 
creased firmness  of  clot;  (3)  human  milk  contains  0.03  per  cent,  of  lime; 
(4)  cows'  milk  contains  0.17  per  cent,  of  lime  (Bunge). 

Enzymes  (Effront  and  Prescott). 

The  enzymes,  soluble  ferments,  zymases,  or  diastases  are  active  organic 
substances,  secreted  by  cells,  and  have  the  property,  under  certain  conditions, 
of  facilitating  chemical  reactions  between  certain  bodies,  without  entering 
into  the  composition  of  the  definite  products  which  result.  These  substances 
play  a  very  important  part  in  the  phenomena  of  assimilation  and  of  dissimi- 
lation of  foods.  In  fact,  most  of  the  foods  which  occur  in  Nature  at  the 
disposition  of  men,  lower  animals,  or  plants,  are  not  directly  assimilable; 
they  require  the  intervention  of  a  diastase  in  order  to  be  transformed  into 
substances  assimilable  and  suitable  for  the  formation  of  new  tissues. 

Starch. 
Starch,  which  serves  in  the  nutrition  of  almost  all  living  creatures,  is 
not  directly  assimilable,  and  in  the  highest  organism  it  undergoes  various 
transformations  before  it  can  be  absorbed.  First  of  all,  it  encounters  the 
enzymes  of  the  saliva,  then  others  in  the  pancreatic  juice,  and  thus  it  is 
transformed  into  maltose  and  glucose,  foods  directly  suitable  for  the  con- 
struction of  tissues.    Meat,  milk,  and  white  of  egg  must  also  be  transformed 


128  INFANT  FEEDING. 

under  the  influence  of  the  diastases  before  becoming  assimilable.  These 
substances  find  the  enzymes  which  can  act  upon  them  in  the  gastric  and 
pancreatic  juices. 

Transformation  of  Starch. — The  cellulose  is  dissolved,  the  starch  is 
transformed  into  maltose,  part  of  which  is  oxidized,  and  part  changed  into 
cane  sugar  by  the  tissue  of  the  seed.  All  these  transformations,  as  well  as 
the  oxidation  itself,  are  produced  by  the  diastases  secreted  during  germina- 
tion. 

One  can  follow  the  course  of  most  of  these  transformations;  for  ex- 
ample, the  solution  and  transformation  of  starch.  For  this  purpose  an  em- 
bryo is  separated  from  the  grain  and  made  to  develop  on  a  gelatinized  must 
in  which  starch  has  been  placed  in  suspension. 

By  observing  the  phenomenon  very  closely  and  by  examining  the  starch 
under  the  microscope,  one  can  see  that  the  grain  of  starch  loses  its  original 
form;  that  it  is  corroded  in  several  places,  and  that  it  then  liquefies  and 
disappears.  In  the  culture  liquid  one  finds  substances  which  did  not  exist 
before:  a  sugar,- and  a  nitrogenous  substance,  the  diastase,  which  is  soluble, 
capable  of  precipitation  by  alcohol,  and  can  itself  produce  a  transformation 
of  starch. 

In  the  assimilation  of  albuminoid  matter  by  cells,  there  occurs  a  phe- 
nomenon quite  analogous  to  the  assimilation  of  carbohydrates.  The  albu- 
minoid substances  are  gradually  transformed  by  the  active  substances  of  the 
cells  into  proteids,  peptones,  and  finally  into  amides. 

We  have  said  above  that  the  diastases  play  an  extremely  important  part 
in  the  phenomena  of  dissimilation.  The  molecules  of  albuminoid  substances, 
hydrated,  decomposed,  and  transformed  by  the  enzymes,  are  regenerated,  in 
the  presence  of  the  protoplasm  of  the  cells,  by  the  process  of  dehydration  and 
molecular  condensation.  The  reconstructed  molecules  undergo  new  changes; 
they  are  again  hydrated,  decomposed,  and  at  the  same  time  gradually  oxi- 
dized. In  this  phase  of  the  transformation  the  albuminoid  molecule  is 
decomposed  into  urea,  glycogen,  fatty  substances,  and  amides.  These  trans- 
formations are  also  due,  in  great  part,  to  the  active  substances  secreted  by 
the  cells. 

Finally,  the  enzymes  are  powerful  producers  of  heat;  the  reactions 
caused  by  the  diastases  are  exothermic  reactions. 

Starch  Digestion  in  Infants. — A.  Jacobi  says:  "It  has  long  been  the 
custom  to  say  that  no  amylaceous  substances  should  enter  into  a  young 
infant's  food  because  it  has  from  Nature  at  an  early  age  no  ferment  capable 
of  digesting  starch.  The  saliva  of  a  newly-born  child — and  it  is  wrong  to 
say  that  there  is  no  saliva  at  this  age — will  dextrinize  starch,  as  any  one  who 
wishes  may  prove  for  himself." 

Chemistry  of  Starch  Transformation. — In  1811  Vauquelin  found  that 
when  starch  was  heated  it  was  changed  into  a  gummy  substance  soluble  in 


PLATE  V 


Microscopic  Appearance  of  Raw  Starcli-graiiules. 


PLATE  VI 


MicTosfopic    A])i)carniu'<'   of   Starcli   j,n-uiuilc's,   sliowiiip'   the  circct    of    Heat. 


CHEMISTRY  OF  STARCH  TRANSIWRMATION.  129 

water.  Kirchof  found  that  starch  boiled  with  diluted  sulphuric  acid  was 
converted  into  a  sugar.  In  1814  he  found  that  a  similar  transformation  of 
starch  was  brought  about  when  the  vegetable  albumin  of  grain  acted  upon 
it.  This  transformation  of  starch  was  greatly  intensified  when  the  grain  was 
malted.  Stromeyer,  in  1813,  discovered  the  iodine  reaction  of  starch.  In 
1819  De  Saussure  isolated  the  sugar  produced  by  the  transformation  of 
starch  and  described  its  crystalline  habit.  Biot  and  Persoz,  in  1833,  gave 
the  name  of  dextrin  to  the  gum  formed  by  the  transformation  of  starch. 
Payen  and  Persoz  gave  the  name  of  diastase  to  the  agent  in  malted  grain 
which  transformed  starch.  Leuchs,  in  1831,  discovered  that  saliva  changes 
starch  into  sugar.  In  1845  Mialhe,  in  a  memoir  to  the  French  Academy, 
announced  the  discovery  and  isolation  of  the  ferment  of  saliva.  This  he 
called  animal  diastase.  He  demonstrated  the  action  of  malt  diastase  and 
the  action  of  animal  diastase  of  the  saliva  upon  starch.  The  transformation 
by  the  former  into  dextrin,  and  the  latter  into  sugar,  was  identical.  It 
was  regarded  as  one  of  the  most  important  discoveries  in  chemical  physi- 
ology. Mialhe,  in  1845,  suggested  that  since  the  action  of  malt  diastase  and 
of  animal  diastase  upon  starch  was  identical,  malt  diastase  should  be  em- 
ployed in  solving  the  problem  of  artificial  feeding  of  infants.  The  action 
of  diluted  acid  upon  starch  transforms  it  into  dextrin,  maltose,  and  glucose ; 
but  glucose  is  the  end  product.  The  action  of  diastase,  however,  whether  it 
be  vegetable  (malt-diastase)  or  the  animal  diastase  of  the  saliva  (ptyalin), 
or  of  the  pancreas  (amylopsin),  transforms  starch  into  dextrin  and 
maltose;  no  glucose  is  formed,  maltose  being  the  end  product.  It  is  espe- 
cially to  be  noted  that  in  the  human  digestion,  not  until  food  has  passed  the 
duodenum  is  any  trace  found  of  dextrose  formed  by  the  transformation  of 
starch. 

Czerny  and  Baginsky,  among  others,  believe  that  starch  is  not  acted 
upon  by  the  saliva  or  by  the  pancreatic  secretions,  but  that  the  intestinal 
bacteria  produced  the  end  products  of  decomposition  resulting,  not  in  sugar, 
but  in  butyric,  lactic,  succinic,  and  propionic  acids.  According  to  these 
authors  intestinal  bacteria  cause  the  acid  reaction  and  the  abdominal  dis- 
tention. 

The  Addition  op  Lime-water,  Bicarbonate  of  Sodium,  or 
OTHER  Alkalies  to  Covps'  Milk. 

Lime-water  is  the  alkali  usually  selected  for  neutralizing  the  acidity 
in  cows'  milk.  It  acts  by  partly  neutralizing  the  acid  of  the  gastric  juice, 
so  that  the  casein  is  coagulated  gradually  and  passes,  in  great  part,  un- 
clianged  into  the  intestine,  to  be  there  digested  by  the  alkaline  secretions. 
As  it  contains  only  ^/^  grain  of  lime  to  the  fluidounce,  the  desired  result 
cannot  be  attained  unless  at  least  a  third  part  of  the  milk-mixture  be  lime- 
water.    Instead  of  lime-water,  2  to  4  grains  of  bicarbonate  of  sodium  may 

• 


130  INFANT  FEEDING. 

be  added  to  each  bottle,  or,  better  still,  from  5  to  15  drops  of  the  saccharated 
solution  of  lime. 

This  solution  is  made  in  the  following  way: — 

IJ  Slaked  lime 1  ounce 

Refined  sugar,  in  powder 2  ounces 

Distilled    water    1  pint 

Mix  the  lime  and  sugar  by  trituration  in  a  mortar.  Transfer  the 
mixture  to  a  bottle  containing  the  water,  and,  having  closed  this  with  a  cork, 
shake  it  occasionally  for  a  few  hours.  Finally  separate  the  clear  solution 
with  a  siphon  and  keep  it  in  a  stoppered  bottle. 

Bicarbonate  of  Soda  Solution  (BaTcing  Soda). — Take  1  grain  of  soda 
bicarbonate  to  Y2  ounce  of  water.  Or  1  drachm  of  soda  bicarbonate  to  1 
quart  of  water.    This  is  the  proper  strength  used  for  diluting  milk. 

Quantity  to  he  Used. — One  tablespoonful  of  the  last-named  solution 
equals  in  strength  1  tablespoonful  of  ordinary  lime-water. 

Both  lime-water  and  soda-bicarbonate  solution  should  be  kept  in  very 
clean,  well-stoppered  bottles  and  in  a  cool  place. 

The  teaching  that  lime-water  should  be  added  to  render  cows'  millc 
alkaline  and  thereby  resemble  human  milk,  has  been  studied  by  Kerley, 
Gieschen,  and  Meyers,  whose  conclusions  are  very  interesting.  They  say 
that:— 

1.  Breast-milk  and  cows'  milk  are  both  acid. 

2.  The  litmus  paper  test  for  milk  is  unreliable  because  of  the  varia- 
tion in  the  quality  of  litmus  paper,  and  the  litmus  taking  part  in  the 
reaction  and  not  acting  as  an  indicator. 

3.  The  effect  of  adding  lime-water  or  bicarbonate  of  sodium  to  feeding 
is  to  retard  or  inhibit  the  formation  of  curds  by  rennet. 

4.  The  teaching  that  lime-water,  bicarbonate  of  sodium,  or  carbonate 
of  potassium  should  be  added  to  fresh  milk  or  feedings  simply  because  they 
are  antacids  is  erroneous. 

5.  The  addition  to  milk  or  feedings  of  alkalies  or  salts  that  become 
alkaline  in  solution  is  an  empirical  method  of  aiding  digestion  by  prevent- 
ing the  formation  of  dense  curds  that  would  slowly  leave  the  stomach  and 
be  difficult  of  digestion  in  the  intestine. 

In  one  respect  I  do  not  agree  with  them,  and  that  is  in  regard  to  the 
addition  of  bicarbonate  of  potassium.  In  weak  infants,  especially  in  maras- 
mic  cases  and  in  those  infants  in  which  "milk  colic"  appears  one  or  two 
hours  after  being  fed  with  cows'  milk,  I  have  found  that  by  the  addition 
of  10  to  15  grains  of  bicarbonate  of  potassium  to  each  feeding  improve- 
ment was  invariably  noted.  I  have  not  found  this  improvement  when 
bicarbonate  of  soda  or  lime-water  was  added. 


CREAM  IN  HOME  MODIFICATION.  131 

Cream. 

When  food  contains  too  little  fat,  or  its  equivalent  (cream),  we  have 
fat-starvation,  which  is  soon  manifested  by  symptoms  of  rickets.  One  of 
the  earliest  symptoms  of  rickets  is  constipation,  showing  deficient  muscular 
tone :   a  distinct  atony  of  the  bowel. 

This  can  be  remedied  by  the  addition  of  fat  or  cream  to  the  food. 
Some  children  are  benefited  by  giving  them  codliver-oil,  butter,  or  olive-oil, 
thus  it  is  plain  that  each  one  desires  to  remedy  the  deficiency  of  fat  in  his 
own  manner. 

In  buying  cream  from  small  milk-stores  one  can  make  a  rough  guess 
at  the  proportion  of  fat  in  cream  by  its  thickness.  A  50-per-cent.  cream  at 
the  ordinary  temperature  of  the  room  runs  from  a  jug  slowly  and  in  a 
thick  stream,  almost  like  thick  mucilage,  whereas  a  16  per  cent,  cream 
runs  almost  as  freely  as  milk.  This  is,  however,  a  crude  way  of  estimating 
the  difference  between  poor  and  rich  cream.  It  is  a  very  important  point 
to  know  exactly  what  percentage  of  cream  we  are  using,  for  such  mixtures 
like  Biedert's,  in  which  1  ounce  of  cream  is  mixed  with  3  ounces  of  water, 
may  agree  very  well  when  we  use  a  16  or  20  per  cent,  cream,  but  might  be 
disastrous  if  we  use  a  cream  containing  40  per  cent,  of  fat.  Such  infants 
v/ould  not  tolerate  this  rich  cream,  and  might  have  troublesome  vomiting. 

Cream  for  Home  Modification. — Ordinary  Cream:  This  is  made  by 
setting  milk  at  night  and  skimming  it  in  the  morning ;  it  is  called  gravity, 
or  skimmed,  cream,  and  contains  16  per  cent,  of  fat. 

Twelve  Per  Cent.  Cream. — Obtained  in  the  city  by  using  equal  parts 
of  ordinary  (20  per  cent.)  centrifugal  cream  and  plain  m.ilk.  In  the 
country  we  must  use  2  parts  of  ordinary  skimmed,  or  gravity,  cream  (16 
per  cent.)  with  1  part  of  plain  milk,  or  by  taking  the  top  layer  of  milk, 
after  it  has  stood  five  or  six  hours,  by  means  of  siphoning. 

Eight  per  cent,  cream  is  obtained  in  the  city  by  diluting  1  part  of  cen- 
trifugal (20  per  cent.)  cream  with  3  parts  of  plain  milk;  in  the  country, 
by  using  1  part  of  gravity  cream  and  2  parts  of  plain  milk,  or  by  using  the 
top  layer  of  milk  that  has  been  standing  five  or  six  hours,  siphoning  it  off. 

How  to  Procure  Cream. — Set  aside  the  ordinary  quart  bottle  of  milk 
on  the  ice  for  several  hours  (from  six  to  eight  hours)  to  allow  the  cream  to 
rise.  After  the  cream  has  risen  draw  the  milk  from  the  bottom  of  the 
bottle;  this  can  be  accomplished  by  means  of  a  siphon. 

To  make  the  siphon  get  a  piece  of  glass  tubing  21  inches  in  length  and 
a  quarter  of  an  inch  in  caliber.  This  can  be  procured  in  any  drug  store. 
German  glass  is  less  liable  to  crack  than  American  glass.  If  the  glass  tubing 
is  longer  than  21  inches  make  a  small  scratch  in  it,  after  measuring  off  21 
inches,  with  a  three-cornered  file,  then  grasp  the  glass  tubing  between  the 
fingers  and  opposing  thumbs  of  both  hands,  having  the  thumb-nails  touch- 


I 


132 


INFANT  FEEDING. 


ing  each  other  on  the  side  of  the  ghiss  just  opposite  to  the  scratch.  On 
attempting  to  bend  tlie  glass  tube  it  will  break  smoothly  across,  and  if 
there  are  any  sharp  edges  they  can  be  smoothed  by  rubbing  dow.n  with  the 
file. 

To  bend  the  glass  tube  to  the  V  shape,  hold  it  in  the  flame  of  an  ordi- 
nary gas  jet  or  alcohol  lamp  for  a  few  moments,  twirling  the  glass  rod  until 
it  softens  sufficiently  to  allow  it  to  be  bent  to  the  required  angle.  The  tube 
should  be  warmed  gradually  at  first,  and  then  put  right  into  the  flame.  It 
is  better  in  bending  the  glass  to  make  one  arm  of  the  siphon  a  few  inches 
longer  than  the  other. 

In  using  the  siphon  hold  it  with  the  angle  down,  fill  it  with  water, 
and  close  the  long  arm  with  the  tip  of  the  finger;  then,  keeping  the  finger 
applied  to  the  long  end,  turn  the  siphon  with  the  angle  up,  and  introduce 


Fig.   43. — C'hapin   Cream   Dipper. 

the  short  arm  into  the  bottle  of  milk,  lotting  it  rest  upon  the  bottom.  On 
removing  the  finger,  the  milk  will  fiow  through  the  tube,  and  continue  to 
do  so  until  the  bottle  is  empty.  It  is,  therefore,  necessary  to  watch  the 
layer  of  cream,  so  that  the  siphon  can  be  lifted  out  of  the  bottle  just  before 
the  cream  reaches  it.  There  will  thus  remain  in  the  milk-bottle  all  of  tbe 
cream  and  a  small  portion  of  the  milk,  the  latter  depending  upon  the  ex- 
pertness  of  the  person  using  the  siphon. 

A  simpler  method  of  obtaining  the  cream  is  by  the  use  of  a  cream 
dipper  (see  Fig.  48).  This  cafi  be  purchased  at  any  large  drug  store.  The 
illustration  explains  itself. 

To  Pasteurize  the  Cream. — Take  a  clear  glass  bottle  having  a  neck  not 
v'M'y  wide;  fit  into  the  same  a  perforated  cork  witli  a  chemical  thermom- 
eter registering  up  212°  F.  The  bull)  of  the  thermometer  should  come 
within  half  an  inch  of  the  bottom  of  the  bottle.    The  cream  is  put  into  the 


MODIFICATION   OF  MILK.  133 

bottle,  and  the  cork  carrying  the  thermometer  is  inserted;  the  bottle  is 
then  placed  in  a  pot  containing  a  couple  of  inches  of  warm  water  and 
allowed  to  heat  on  the  stove.  The  thermometer  should  be  watched  until 
it  reaches  140,  taking  care  that  it  does  not  go  above  140.  When  the  ther- 
mometer has  reached  this  point,  set  the  pot  back  on  the  stove  where  it  will 
cool  off,  and  allow  it  to  remain  there  for  twenty  minutes.  At  the  end  of 
this  time  substitute  a  plug  of  absorbent  cotton  for  the  cork  containing  the 
thermometer.  Great  care  must  be  taken  to  keep  the  absorbent  cotton  dry. 
Cream  thus  prepared  is  pasteurized,  and  will  keep  sweet  and  fresh  for 
twenty-four  hours  without  being  kept  on  ice,  and  all  that  is  necessary  in 
removing  a  portion  from  the  bottle  is  to  be  sure  that  the  cotton  plug  does 
not  become  moist,  or,  if  it  should,  to  replace  it  with  a  dry  piece  at  once. 

To  Clean  the  Glass  Siplioii. — It  is  advised  to  fill  it  with  water  imme- 
diately after  using  it,  and  the  ordinary  tube-brush  having  eighteen 
inches  of  wire  added  to  it  will  permit  thorough  cleansing.  Nothing,  how- 
ever, will  be  found  as  good  as  thorough  boiling  in  plain  water  to  which  a 
pinch  of  soda  has  been  added. 

Modification  of  Milk. — It  has  been  shown  previously  that  the  percent- 
ages of  fat  in  Avoman's  and  in  cows'  milk  are  about  tlie  same,  that  the 
quantity  of  sugar  is  rather  lower  in  cows'  milk,  and  that  the  quantity  of 
casein  and  albumin  is  greater  in  cows'  milk,  as  is  also  the  ash.  Experience 
has  shown  that  cows'  milk  must  be  dikited  before  it  can  safely  bo  fed  to 
infants.  Simply  diluting  the  milk  reduces  the  percentages  of  fat  and  sugar 
too  much ;  so  that  the  practice  of  adding  cream  and  sugar  has  arisen,  but  the 
processes  that  have  been  advocated  for  ol)taining  the  desired  additional 
(quantities  of  fat  and  sugar  have  been  too  complicated  for  general  use. 

The  top  9  ounces  of  a  quart  of  milk  on  which  the  cream  has  risen  will 
be  about  three  times  as  rich  in  fat  as  the  whole  milk,  the  top  15  or  16 
ounces  will  be  about  twice  as  rich  as  the  whole  milk,  while  the  other 
ingredients  remain  about  the  same  as  in  whole  milk. 

For  babies  under  three  months  of  age  the  top  9  ounces  of  a  quart  of 
milk  on  which  the  cream  has  risen  should  be  diluted  from  three  to  ten 
times  and  1  part  of  sugar  added  to  25  parts  of  food. 

For  babies  three  to  six  months  old  the  top  1(3  ounces  of  a  quart  of 
milk  on  which  the  cream  has  risen  should  be  diluted  two  or  three  times 
and  1  part  of  sugar  added  to  25  or  30  parts  of  food. 

For  ba1)ies  six  to  nine  months  old  tlie  top  20  ounces  of  a  quart  of 
milk  on  which  the  cream  has  risen  should  l)e  diluted  one-half  to  one  time 
and  1  part  of  sugar  a(1(lo(l  to  50  parts  of  food.  An  even  tablespoonful  of 
granulated  sugar  equals  half  an  ounce. 

By  following  this  method  the  infant  commences  on  weak  mixtures 
that  show  about  the  same  composition  and  variations  as  woman's  milk 
and  gradually  takes  food  richer  in  casein  until  plain  milk  is  reached. 


134 


INFANT  FEEDING. 


The  diluents  used  are  water,  gruels,  or  dextrinized  gruels,  which  are 
simply  ordinary  gruels  the  starch  of  which  has  been  converted  into  soluble 
forms,  leaving  the  cellulose  and  proteids  of  the  cereal  in  a  finely  divided 
state.    The  effect  of  the  different  diluents  will  be  mentioned  farther  on. 


Table  No.  25. — Feeding-table. 

(Gl'O.  C.  Carpenter,  London). 


Age. 

Intervals  of 
Feeding. 

Number  of 
Times  in 
24  Hours. 

Average  Amount 
Each  Feeding. 

Average  in 
24  Hours. 

1st  week      

1st  month 

2d  month 

3d  and  4th  months 
5th  and  6th  months 

2    hours 

2  hours 
2^  hours 

3  hours 
3    hours 

10 

8 
8 
7 
6 

1  OZ. 

li  to  2  oz. 

3  to  4  oz. 

4  to  5  oz. 
6    to  7  oz. 

10  OZ. 
12  to  16  oz. 
20  to  30  oz. 
30  to  35  oz. 
34  to  40  oz. 

Biedert's  Cream  Mixtures.^ — The  following  formulae  are  from  the  fourth 
edition  of  his  boolc  on  "Infant-feeding,^'  published  in  1900 : — 


Table 

No.  26. 

Formula. 

Cream. 

Water. 

Milk-sugar. 

Milk. 

Casein. 
Per  Cent. 

Fat. 
Per  Cent. 

Sugar. 
Per  Cent 

1st  month 

I. 

4  oz. 

12  OZ. 

4Hr. 

09 

2.5 

5 

2d  month  . 

II. 

4  oz. 

12  oz. 

4*  dr. 

2  oz. 

1.2 

2.6 

5 

3d  month  . 

III. 

4  oz. 

12  oz. 

4^  dr. 

4  oz. 

1.4 

2.7 

5 

4th  month  . 

IV. 

4  oz. 

12  oz. 

4.i  dr. 

8  oz. 

1.7 

2.9 

5 

5th  month . 

V. 

4oz. 

12  oz. 

4Jdr. 

12  oz. 

2.0 

3.0 

5 

6th  month . 

VI. 

•    • 

Soz. 

3    dr. 

24  oz. 

2.5 

2.7 

5 

According  to  recent  milk  analyses,  it  is  necessary  to  take  6  per  cent., 
which  is  equivalent  to  5  ^/j  drachms  of  sugar  to  12  ounces  of  water.  It  has 
also  been  shown  that  cane  sugar  in  the  same  quantity  as  milk  sugar  can  be 
used.  In  using  Formula  5,  especially  if  an  infant  is  constipated,  it  is  ad- 
visable gradually  to  substitute  milk  for  the  water;  thus  we  take  away  1 
ounce  of  water,  and  add  1  ounce  of  milk,  until  our  formula  is : — 


Cream. 
4  ounces. 


Sugar-water. 
4  ounces. 


Milk. 
20  ounces. 


And  gradually  arrive  at  a  whole  milk  feeding;  in  other  words,  give  pure 
cows'  milk  undiluted.  Biedert  claims  that  frequently  diluted  cows'  milk  was 
not  well  borne,  especially  on  weak  stomachs,  and  the  change  to  the  cream 
mixture  resulted  in:  decided  benefit.  He  believes  that  the  cream  mixture  is 
assimilated  far  better  than  the  diluted  milk  mixtures  not  containing  cream. 
Thus  he  claims  that  the  cases  ol'  constipation  alternating  with  diarrhoea 
and  lastly  mucous  enteritis  are  those  in  which  the  cream  mixture  will  render 


^  Biedert's  cream  is  sold  in  this  country  under  the  name  of  Ramogon. 


THE  RIPENING  OF  CREAM.  135 

satisfaction;  but  he  advises  that  a  definite  rule  must  prevail  regarding  the 
amount  of  fat  contained  in  the  cream,  and  furthermore  that  an  8  to  10 
per  cent,  cream  be  used. 

Biedert's  Directions  for  Making  Cream.  —  From  1  to  2  quarts  of 
milk  are  put  into  a  broad  jar  (glass)  on  the  ice,  for  no  longer  than  two 
hours.  He  then  removes  with  a  flat  spoon  from  3  ^/^  to  7  ounces  of  the 
thin  white  creamy  layer  over  the  bluish  mass  of  milk.  In  removing  the 
above  quantity  a  small  portion  of  the  milk  will  be  removed  with  it.  In 
cases  of  severe  constipation  Biedert  insists  on  removing  pure  cream. 

The  above  Formula  I  is  for  the  first  month,  Formula  II  is  for  the 
second  month,  Formula  III  is  for  a  child  from  three  to  four  months,  For- 
mula IV  is  for  fourth  to  fifth  month.  Formula  V  is  for  the  sixth  to  seventh 
month,  and  Formula  VI  is  for  the  eighth  to  tenth  month. 

It  is  understood  that,  while  feeding,  the  general  condition  of  the  child 
is  the  criterion,  and  thus  we  shall  frequently  be  compelled  to  change  the 
formula  for  individual  requirements,  some  infants  requiring  far  more  cream 
than  the  above-mentioned  formulae  give  them  for  their  age  and  their  weight, 
whereas  the  great  majority  will  require  a  modification  of  far  less  cream 
than  the  above-given  formulae  for  their  age  and  weight. 

The  indiscriminate  feeding  of  cream,  to  strengthen  the  hahy,  cannot 
he  too  strongly  condemned.  Many  a  dyspeptic  owes  his  trouble  to  over- 
feeding by  a  too  good  mother  or  nurse.  When  cream  is  added,  and  the  pro- 
portion of  fat  or  proteid  is  too  large,  vomiting  will  result.  Stuffing  delicate 
children  with  cream,  regardless  of  their  digestive  power,  cannot  be  too 
strongly  condemned.  When  improper  food  is  given,  and  the  infant's  stom- 
ach is  overtaxed,  the  excess  of  food  iriitates  and  may  cause  vomiting.  If, 
however,  the  food  remains,  then  the  gastric  mucosa  is  inflamed  by  bacterial 
fermentation  of  stagnant  food.  This  may  result  in  diarrhoea  or  in  fermen- 
tative gastntis,  and  cause  chronic  enlargement  of  the  stomach. 

The  Eipeninq  op  Cream.* 

From  the  following  table  it  will  be  seen  that  the  number  of  bacteria 
in  the  unripened  cream  is  very  much  more  variable  than  that  present  in  the 
ripened  cream.  In  the  unripened  cream  the  number  was  sometimes  as  small 
as  1,000,000  per  cubic  centimeter,  and  in  one  case  it  was  so  small  that  it 
could  not  be  determined  with  the  high  dilutions  which  were  used.  At  the 
other  extreme  we  have  one  sample  of  unripened  cream  collected  in  February 
with  220,000^000  bacteria  per  cubic  centimeter.  In  the  other  experiments 
the  figures  range  between  these.  The  significance  of  this  fact  is,  of  course, 
simply  that  the  cream  as  collected  in  the  creamery,  which  we  speak  of  as 
unripened,  is  really  in  different  stages  of  ripening  by  the  time  it  reaches 


*  By  Conn  and  Esten  (Storrs  Agiicultural  Experiment  Station). 


136 


INFANT  FEEDING. 


the  creamery.  The  samples  with  large  numbers  of  bacteria  are  already  well 
ripened,  while  those  with  small  numbers  have  only  begun  their  ripening 
process. 

Table  No.  27. — Number  of  Bacteria  in  Unripcncd  and  Bipcncd  Cream. 


Data 


October 

May 

May 

May 

July 

July 

July 

July 

July 

July 

October 

October 

November 

DeceinVjer 

December  11, 

October       19, 

October      26, 

November    2, 


28, 
22, 
26, 
29, 
2,* 

5,* 

12,* 

16,* 

19, 

22, 

13, 

30, 

3, 

8, 


Temperature 

During  Time  of 

Kipening. 


64®  for  20  hours 
64-68°  for  20  bours 
66°  for  18  hours 
60-70°  for  16  hours 

63-65°  for  16  hours 


71° 
71° 
71° 

68° 
60  65 


for  17  hours 
for  16  hours 
for  14  hours 

for  18  hours 
for  28  hours 


60-70°  for  29  hours 
60-70°  for  24  hours 
60-70°  for  24  houra 
60°        for  21  hours 


In 

Unripened 
Cream. 


Per  c.  a 

125,000,000 

56,000,000 

60,000,000 

1H6,000,000 

214,000,000 

178,000,000 

67,000,000 
134,000,000 

75,000,000 
115,000,000 

72,000,000 
107,000,000 

39,000,000 
4,000,000 

35,000,000 

39,000,000 
115,000,000 
158,000,000 


In 
Ripened 
Cream. 


Per  c.  a 

350,000,000 
354,000,000 
320,000,000 
295,000,000 
380,000,000 

392,000,000 

190,000  000 
213,000,000 
286,000,000 
428,000,000 
291,000,000 
199,000,000 
234,000,000 
238,000,000 
200,000,000 
380,000,000 
297,000,000 
355,000,000 


Rem  arks. 


Good  aroma 
Good  aroma,  gas 
Good  aroma 
(  Good  aroma,  thick. 
\     slightly  acid 
Good  aroma,  acid 

Slow  ripeuing 


Ripe  when  collected 


•  Hot  Weather. 


The  number  of  bacteria  in  the  ripened  cream  varies  far  less.  The 
smallest  number  found  was  50,000,000;  the  largest  number,  578,000,000. 
While  this  difference  is  of  course  in  actual  numbers  a  large  one,  the  pro- 
portionate difference  is  very  much  less  than  in  the  unripened  cream;  one 
sample  of  unripened  cream,  for  instance,  containing  two  hundred  and  twenty 
times  as  many  bacteria  as  another  sample,  while  the  largest  number  in  the 
ripened  cream  was  only  about  eleven  times  as  great  as  the  smallest  number. 

The  only  conclusions  of  any  significance  from  these  facts  are  that  the 
cream  received  by  creameries  is  in  various  stages  of  ripening,  and  secondly, 
that  the  number  of  bacteria  in  ripened  cream  does  not  run  much  over  500,- 
000,000  per  cubic  centimeter.  In  the  well  ripened  cream  this  number  is 
rarely  surpassed. 

General  summary  of  the  conclusions  which  were  drawn  from  the  long 
series  of  experiments  in  regard  to  the  actual  bacteriological  development  that 
occurs  during  the  normal  ripening  of  cream: — 

1.  Milk  as  it  is  drawn  from  the  cow  contains  great  quantities  of  bac- 
teria; most  of  these  are  miscellaneous  forms  of  liquefying  bacteria  and 
other  non-acid  species.  At  the  outset  the  number  of  acid  bacteria  is  very 
Email. 


BACTERIA  IN  CREAM.  137 

2.  All  species  of  bacteria  increase  during  the  setting  of  the  milk  for  the 
separation  of  the  cream. 

3.  For  a  few  hours  the  alkaline  bacteria  and  the  others  which  have 
been  included  under  the  head  of  miscellaneous  forms  increase  quite  rapidly, 
while  the  lactic  bacteria  are  hardly  evident. 

4.  After  about  twelve  hours  the  lactic  bacteria  have  increased  so  much 
as  to  be  as  numerous  as  the  others,  and  from  this  time  on  they  continue  to 
increase  with  great  rapidity  until  a  maximum  is  reached  at  about  forty-eight 
hours ;  after  this  the  numbers  gradually  decrease  and  they  finally  practically 
disappear. 

5.  The  ripened  cream  contains  prodigious  numbers  of  bacteria,  larger 
numbers  than  are  known  in  any  other  natural  medium.  They  are,  however, 
nearly  all  lactic  bacteria. 

6.  After  the  first  twelve  hours  all  species  of  bacteria  except  the  two 
lactic  species  decrease  in  relative  numbers  and  finally  absolutely  disappear. 

7.  The  cream  which  is  received  by  a  creamery  is  already  partly  ripened, 
as  indicated  by  the  immense  numbers  of  bacteria  it  contains.  All  of  the 
changes  which  occur  in  the  cream  under  the  influence  of  the  miscellaneous 
bacteria  have  already  occurred,  and  the  ripening  that  takes  place  in  the 
creamery  is  due  wholly,  or  almost  wholly,  to  the  growth  of  the  acid  bacteria. 

8.  A  ripened  cream  is  almost  a  pure  culture  of  acid  bacteria,  but  this 
does  not  mean  that  the  ripening  has  been  produced  by  these  acid  bacteria 
alone. 

9.  That  the  lactic  bacteria  play  an  important  part  in  the  ripening  is 
perfectly  evident;  that  they  are  the  sole  cause  of  the  changes  occurring  in 
the  ripening  is  not  so  evident. 

10.  The  peculiar  flavor  of  June  butter,  which  is  so  much  desired  by 
the  butter  maker,  is  not  due  to  the  development  of  the  common  lactic  bac- 
teria. Butter  ripened  during  the  winter  months  develops  the  two  species  of 
lactic  bacteria  as  abundantly  and  as  quickly  as  does  that  ripened  in  June, 
but  the  flavor  does  not  make  its  appearance.  In  the  last  three  experiments 
recorded  the  June  flavor  was  very  noticeable  in  the  cream,  but  the  develop- 
ment of  the  acid  bacteria,  or  the  two  species  referred  to,  was  practically  the 
same  as  in  all  of  the  previous  experiments.  The  June  flavor,  therefore, 
cannot  be  due  to  these  common  lactic  bacteria. 

11.  To  what  this  June  flavor  is  due  we  are  not  as  yet  satisfied.  Whether 
it  will  prove  to  be  due  to  the  large  growth  of  miscellaneous  bacteria  during 
the  first  few  hours  of  ripening,  or  whether  it  is  due  to  a  difference  in  the 
chemical  nature  of  the  cream,  remains  for  further  experiments  to  decide. 

Toi'  Milk. 

Top-milk  is  obtained  directly  from  fresh  milk  by  the  so-called  ^'gravity 
process."    Cream  contains  a  great  deal  of  fat,  usually  three-fifths  of  cream 


I 


138  INFANT  FEEDING. 


is  fat;  this  floats  on  the  surface  of  the  watery  milk.  If  a  quart  bottle  of 
the  average  city  milk  is  put  into  ice-water  or  upon  ice  in  the  refrigerator, 
and  removed  after  four  or  five  hours,  we  can  skim  off  from  the  top  about 
10  oimces  of  an  8  per  cent,  cream;  after  six  hours  about  6  ounces  of  12 
•per  cent,  cream.  This  I  shall  speak  of  as  top-milk.  Frequently,  instead  of 
skimming  the  cream,  the  lower  portion  is  siphoned  off,  leaving  the  cream  in 
the  glass  bottle.  When  cream  is  removed  by  a  centrifugal  machine,  it  is 
known  as  centrifugal  cream.  It  can  be  separated  much  more  quickly  than 
so-called  gravity  cream,  which  must  rise  naturally  and  slowly  from  milk  t 

that  is  allowed  to  stand. 

My  experience  with  top-milk  feeding  has  been  tad.  Infants  fed  on 
top-milk  diluted  with  water  have  gradually  shown  dyspeptic  symptoms,  and 
it  was  necessary  to  give  the  stomach  absolute  rest  by  using  very  dilute  solu- 
tions of  milk  and  rice  or  barley  water.  An  interesting  case  of  top-milk 
feeding  came  to  my  office  recently: — 

Child  three  months  old  having  stools  containing  curds  and  greenish  mucus. 
All  gastric  disturbances  were  present.  Vomiting  followed  each  feeding.  When  the 
top-milk  was  stopped  the  gastric  symptoms  subsided. 

My  rule  has  been  to  give  bottle-fed  infants  first,  a  very  minute  quantity 
of  milk,  1  part  of  milk  with  3  or  4  parts  of  water.  If  the  same  is  assimi- 
lated, I  increase  the  quantity  of  milk  and  decrease  the  water  from  week  to 
week.  Top-milk  or  cream  feeding  should  be  used  cautiously.  I  believe 
that  more  cases  of  dyspepsia  are  caused  by  this  heavy  form  of  feeding  than 
by  any  other  method  of  feeding. 


CHAPTEK  III. 


HOME  MODIFICATION  OF  MILK. 


Bottle-feeding  or  Hand-feeding. 

The  following  utensils  are  required  for  the  home  modification  of 
milk: — 

Two-quart  pitcher,  "j 

Funnel,  l  glass  or  porcelain. 

One  large  spoon,     J 

One  dozen  4-ounce  bottles  (later  substitute  8-ounce  bottles). 

One  dozen  anti-colic  nipples. 

One  box  non-absorbent  cotton. 

One  saucepan    (for  heating  milk). 

One  high  saucepan   (for  warming  bottle  before  feeding). 

General  Eules  for  Bottle-feeding. 

No  set  rule  can  be  given  for  all  infants.  Each  infant's  desires  must 
he  studied.  The  stomach  capacity  of  one  infant  may  he  6  ounces  at. the  age 
of  two  months,  while  another  equally  healthy  infant  will  he  satisfied  with 
^  ounces  at  one  feeding. 

Table  No.  28. 


Age  of  Child. 

Frequency  or 

Interval  of 

Feeding. 

Number  of 

Feedings  in 

24  Hours. 

Average  Amount 

for 

Each  Feeding. 

Average  Amount 

in 

24  Hours. 

From  birth  to 
1  month 

2  hours 

10 

1  to  2 

ounces 

10  to  20 
ounces 

1  to  2  months 

2\  hours 

8 

3  to  4 
ounces 

24  to  32 

ounces 

2  to  4  months 

3  hours 

6  or  7 

3J  to  5 
ounces 

24  to  35 
ounces 

4  to  6  months 

3  hours 

6 

5  to  7 
ounces 

30  to  42 

ounces 

6  to  9  months 

3.}  to  4 

hours 

5 

8  ounces 

40  ounces 

9  to  12  months 

4  hours 

4 

8  ounces 

32  ounces 

1  year 

4  hours 

4 

8  ounces 

32  ounces ' 

*  See  article  on  "  Additional  Fooda  During  the  Nursing  Period,"  ia  Chapter  on  "Breast-feeding." 

(139) 


140  l.NFAM'  FEEDING. 

TIr'i^c  individual  pccidiaritics  must  l)o  taken  into  consideration  when 
estinuitinji;  the  quantity  of  food  for  each  ineaL  An  infant  that  cries 
after  takiuii'  its  l)()ttle.  and  })uts  its  fing-ers  to  its  nu)utli  and  whines  and 
fret;-,  if  (ithcrwise  normal,  is  generally  underfed.  When  children  arc 
underfed  they  usually  have  greenish,  spinach-like  stools. 

Formula  Xo.  1  (f(ir  a  c-liild  from  hirtli  to  one  month  old): — • 

IJ    Kaw  cows"  milk   4   oiiiiccs 

Barley  \\ater'   1  (J  ounces 

Granulated  suj^ar    I   uunt-e 

]Mix  tlioruuylilv.  Iloat  in  a  new  .saueejjan  unlil  steam  lises.  C'ltntinue  steani^ 
ing  at  same  temperature  ten  minutes.  Divide  into  ten  bottles  (2  ounces  each). 
Insert  in  the  necks  uf  the  bottles  large  cotton  stoijpers.  Place  the  bottles  in  a 
refrigerator,  but  not  on  ice.  Warm  before  feeding,  by  placing  bottle  into  a  deep 
saucepan  of  hot  water  until  the  food  reaches  tlie  body  temperature. 

Formida  Xo.  "3  (for  a  i-hikl  from  one  to  two  inonths  old): — 

IJ   Raw   cows'    milk    7  ounces 

Barley   water    20  ounces 

Granulated   sugar    1  '/s  ounces 

Divided  into  eight  bottles,  each  bottle  containing  about  3  ounces.  Feed  every 
two  and  one-half  hours. 

Formula  Xo.  3  (for  a  child  from  two  to  four  months  old): — 

IJ   Raw   cows'    milk     12  ounces 

Barley   water    , 2;}  ounces 

(Jranulated   sugar    1  Va  ounces 

Di\  ide  into  seven  Ijottles,  each  bottle  containing  about  5  ounces.  Feed  every 
three  hours. 

Formula  Xo.  4  (f(u*  a  child  from  four  to  six  months  old): — ■ 

IJ   Raw  cows'  milk    22  ounces 

Bailey  water    20  ounces 

(Granulated  sugar   1   ounce 

Divide  into  six  bottles,  each  bottle  containing  al>out  5  V2  ounces.  Feed  every 
three  hours. 

Formula  Xo.  .")  (for  a  child  from  six  to  nine  months  old): — 

H    Raw    cows'    milk     28  ounces 

Barley    water    12  ounces 

(Jrainilated  sugar 1  -/a  ounces 

Divide  into  five  bottles,  each  bottle  containing  about  8  ounces.  Feed  every 
three  and  one-half  hours. 


^  For  formula  of  barley  water,  and  other  diluents,  see  "Dietary." 


RULES  FOR   BOTTLE-FEEDING.  141 

Formula  Xo.  (i  (for  a  child  I'l'om  nine  lo  twelve  months  okl): — 

R   Raw    cows"    milk     27  ounces 

Itarlcy    water    5  ounces 

(iiainilatcd   sugar    1  -/..  ounces 

Divide  into  four  liottles,  cacli  bottle  containing  8  ounces.  Feed  every  four 
hours. 

Formula  No.  T  (for  a  child  over  1  year  of  age): — 

IJ   Raw    cows'    milk     32  oimces 

Oranulated   sugar    1  -/a  ounces 

Di\ided  into  four  bottles,  each  bottle  containing  S  ounces.  Feed  every  four 
hours.' 

The  modification  of  cows'  milk  with  the  addition  of  Eskay's  albu- 
minized food  has  served  me  very  well.  The  food  has  a  decided  mechanical 
effect  on  the  casein,  splitting  it  up,  thus  rendering  it  mcn-e  tlocculent.  To 
children  over  five  months  I  usually  give  the  following: — 

IJ   Raw   cows'    milk 5  ounces 

Barley    water    3  ounces 

Eskay's  albuminized   food 1  teaspoonful 

Granulated    sugar    1  teaspoonful 

Mix  the  ingredients  tlioroughly  and  lieat  in  a  saucepan  until  the  steam  rises. 
It  is  important  to  use  none  but  fresh  milk,  and  milk  that  contains  at  least  4  per 
cent,  of  fat.     If  less  fat  exists  in  the  milk  a  tendency  to  constipation  may  arise. 

The  addition  of  a  teaspoonful  of  calcined  magnesia  or  a  teaspoonful 
of  the  fluid  mill:  of  magnesia,  sold  in  drug  stores,  given  with  the  morning 
bottle,  will  correct  constipation.  From  month  to  month  as  the  child  in- 
creases in  weight  and  assimilates  the  food,  we  can  add  more  of  the  P]skay's 
food,  more  cows'  milk,  and  reduce  the  barley  water. 

The  following  formuhp  have  proven  very  successful  and  are  copied 
frotn  my  book  on  "Infant-Feeding  in  Health  and  Disease"-  (Chapter  XXI, 
p.  152);- 

OtIIKK    IiTbHS    FOR    BoTTLK-FKi:!)!  \G. 

For  a  C'liiJd  III  Jlirlli.  Funinihi  1. — The  new-born  infant's  food  should 
consist  of  (home  niodilication) : — 

FwR.\Ur,.V    KOI!    MOMK    I'SE. 

Fat    l.C  (ream     2  ounces 

Sugar 5.0  .Milk    2  ounces    ■ 

I'roteids     O.?.!  Lime-water    1   ounce 

Reaction    alkaline.  \\'at<'r     ].")  ounces 

I\Iilk-sug:ir     (I  '/,   drachms 

'  See  article  on  "Additional  iMiods  Dining  the  Xursing  Period,"  in  the  cha])ter 
on   ■•P.reast-milk." 

-Louis  Fischer:  "Infant  Feeding  in  lleiilth  and  Disease,"  Tliird  Edition,  F.  A. 
Davis  ('omj)any. 


142  INFANT  FEEDING. 

The  above  formula  (1)  is  to  be  dividod  into  10  feedings  of  2  ounces 
eacli,  (»r  (iO  cubic  centimeters  eacli,  ami  should  be  heated  for  twenty 
minutes  to  140°  F.,  thougli  JJussell,  of  Wisconsin,  luis  proved  l)y  experi- 
UK'ut  that  tubercle  bacilli  are  desti-ovcd  at  140°  F.,  ^vllich  temperature 
may  answer  when  a  good  source  of  milk  is  found. 

The  cream  must  contain  at  least  10  p'er  cent,  of  fat.  This  is  known 
as  a  decimal  cream,  and  can  be  referred  to  under  the  heading  of  "Cream 
for  Home  Modification." 

Child  1  Muni]}.    Foniiida  .5.— Take  of  :— 

Fat 2.0  Cream    4  ounces 

Sugar    5.0  Lime-water    1  ounce 

Proteids    0.75  Water 15-25  ounces 

Lime-water    5.0  Milk-sugar G  ^/,,  drachms 

The  al)Ove  quantity  is  to  l3e  divided  into  ten  feedings,  and  heated  for 
twenty  minutes  to  140°  F.,  and  the  infant  to  be  fed  (mce  every  two  hours- 
In  Formula  2  we  have  added  more  cream  and  purposely  left  out  the  milk. 
]f  the  infant  thrives  on  this  mixture,  then  we  can  substitute  1  ounce  of 
milk  instead  of  1  ounce  of  water.  Some  children  will  not  l)e  satisfied  with 
less  than  3  to  4  ounces;  there  is  no  reason  wliy  they  should  not  receive 
the  above  quantity  if  their  general  condition  warrants  it. 

After  the  end  of  the  second  mouth  the  ([uantity  of  food  can  1)0 
increased  if  the  infant's  ap]K'tite,  sleep,  stools,  and  general  condition  war- 
rant it.  Thus,  instead  of  feeding  a  bottle  of  Formula  2,  we  simply  add  1 
ounce  of  milk  for  the  third  month  to  Formula  2.  Frequently  the  addition 
of  1  or  2  ounces  of  sterile  water  to  the  fornnila  will  give  a  larger  bulk  ami 
satisfy  the  infant.  iVs  every  infant's  appetite  and  gastric  capacity  is 
different,  we  must  "carefully  note  the  condition  of  the  baby  after  its 
feeding  before  resorting  to  fixed  rules. 

At  Four  Monlhs.     Formula  3. — Take  of: — 

Fat    3.5  Cream    7  ounces 

Sugar     6.5  Milk   1  ounce 

Proteids     1.5  Lime-water    1   ounce 

Lime-water    5.0  Water 25-32  ounces 

Milk-sugar G  Vi  drachms 

Divide  into  eight  bottles;    heat  as  above  to  140°  F. ;    fei>d  every  three  hours. 

From  Nine  to  Twelve  Monlhs.     Formula  Jf. — Take  of: — 

Fat   4.0  Cream    S  ounces 

Sugar    7.0  Milk    7  Va  ounces 

Proteids    3.0  Lime-water    1  ounce 

Lime-water    5.0  Water    20-30  ounces 

^lilk-sugar G  V4  drachms 

The  above  to  be  divided  into  live  feedings,  heated  to  140°  F.,  and  one  bottle  fed 
ev('r\-   four  hours. 


ILLUSTRATIVE  BOTTLE-FEEDING.  143 


Clinical  Illustrations  of  How  to  Feed   (from  the  Author's  Private 

Records). 

Case  I. — Baby  V.,  was  referred,  to  me  for  treatment  April  3,  190L 

The  child  was  three  and  a  half  months  old  at  time  of  commencing  treatment, 
and  weighed  8  pounds  and  10  ounces. 

History:  Breast-fed  about  two  weeks;  since  then  fed  on  milk  dUuted  with 
water  and  milk-sugar;  food  was  steamed  foity  minutes.  Child  had  always  been 
constipated,  always  cries,  and  suffers  with  coUc. 

Gave  barley  and  condensed  milk  with  lime-water;  child  seemed  to  do  well; 
weight  was  about  10  pounds.  After  several  weeks  cream  was  added  to  the  food. 
After  this  addition  of  cream  the  child  vomited  and  cried,  had  severe  colic,  waa 
restless  by  day,  and  had  insomnia  at  night.  Its  bowels  were  so  disturbed  that  all 
milk  was  stopped.  Barley-water  was  the  only  food  tolerated.  Then  cereal  milk 
was  prescribed.  The  cereal  milk  was  not  retained;  child  vomited  after  each  feeding, 
then  was  constipated,  which  alternated  with  greenish,  dark  stools.  Infant  was 
emaciated;    the  stools  contained  mucus. 

Physical  Examination:  Very  emaciated  child;  temperature,  100°  F.;  abdomen 
distended,  very  Hatulent;  skin  dry,  elasticity  lost;  hei-petic  eruption  on  lips  and 
around  anus;  pulse,  140  and  feeble;  throat  clean;  lungs  normal;  heart-sounds, 
very  feeble;    left  inguinal  hernia. 

Diagnosis:     Athrepsia,  resulting  from  chronic  gastric  catarrh. 

Food  ordered: — 

Pure  cows'  milk   2  ounces 

Oatmeal-water     2  ounces 

Granulated  sugar   V2  teaspoonful 

Peptogenic   powder    V2  teaspoonful 

Feed  eveiy  thi'ee  hours.    Alternate  with: — 

Pure  cows'  milk    2  ounces 

Barley-water 2  ounces 

Granulated  sugar  V2  teaspoonful 

Peptogenic  powder '/»  teaspoonful 

Heat  this  mixture  slowly  for  ten  minutes,  then  boil  one  minute. 

Mother  reports  that  the  child  takes  food  well,  stools  are  yellow,  and  child 
passed  a  good  night,  but  still  has  eructations  and  seems  colicky.  The  food  was 
continued,  and  the  child  gained  ioi  (unices  in  seven  days. 

^\'eigllt,  April     .3 8  pounds  and  10  ounces 

Weight,  April  10 !)  pounds  and     4  ounces 

Weight,  April   17 9  pounds  and     8  ounces 

Weight,  April  21 9  pounds  and  14  ounces 

Weight,  May      1 10  pounds  and     4  ounces 

Weight,    June     .3 12  pounds  and     5  ounces 

Weiglit,  June   1.").  . .    13  pounds  and  12  ounces 

Weight,  Dec.     20 19  pounds 

Extract  of  malt  was  ordered,  V2  teaspoonful  tliree  times  a  day,  Eveiy  week 
tlie  foi inula  was  clianged,  commencing  with:  — 

Milk    2  ounces  ") 

Barley-water  or  oatuieal-water 2  ounces  [    Formula      I 


144 


INFANT  FEEDING. 


} 


Formula    TI 


Formula  III 


Ono  wnok  later  I  ordorpd:  — 

Milk    - 2  V2  ounces 

Barley-water  oi'  oatmcal-wiilcr 2 '/2  oiinc-es 

Feed  every  three  hours. 

Kaw  milk   3  ounces 

Barley-water  or  oatmeal-water 3  ounces 

Peptogenie   powder    2  teaspoontuls 

Granulated   sugar    '/j  teaspoonful 

Feed  every  three  or  three  and  one  lialf  hours. 

I  ordered  this  infant  to  be  awakened  by  day  for  fe^-ding,  but  not  to  be  disturlied 
at  night.  When  the  child  cried  afttr  feeding  wlicn  5  months  old,  instead  of  giving 
Fornuila  III,  I  ordered:  — 

Haw    milk    4  V2  ounces 

Barley-water    2  V2  ounces 

Peptogenie  pow  der   V2  measure 

(Jranulattd  sugar   Va  teaspoonful 

The  above  for  one  feeding.  Feed  every  three  or  three  and  one-half  hours.  Sub- 
stitute oatnual-water  for  barley-water  eveiy  other  day. 


>    Formula  IV 


>   Formula    V 


Milk    5  V2  ounces 

Barley-water   2        ounces 

Peptogenie  powder   V2  measure 

Granulated  sugar   V2  teaspoonful 

Alternate  with  oatmeal-water.      Feed  every  three  and  one-half  or  four  hours. 

Case  II. — Dorothy  L.  F.,  cicicn  mouths  old,  was  refened  to  me  for  treatment 
on  March  18,  1901,  by  Dr.  H.  J. 

The  history  elicited  was:  The  baby  is  still  nursing  and  appears  undersized, 
fery  anaemic,  and  poorly  developed.  No  evidence  of  teething;  cannot  walk  nor  talk. 
Has  had  summer  complaint.  Eecently  suffered  with  constipation.  Had  diairhcEal 
stools  some  time  ago;  stools  were  greenish  in  color,  and  contained  curds  and  mucus. 
Has  had  a  cough  lasting  three  weeks;  also  sniffles.  A  restless  sleeper,  rarely  sleep- 
ing more  than  one-half  hour  at  a  time  during  the  day.  Is  frequently  very  raw  be- 
tween thighs  and  on  buttocks.      Child  is  very  flatulent. 

Physical  Examination:  A  very  frail  child;  large  abdomen;  slight  evidence 
of  rickets;  very  feeble  heart-action;  lungs  normal;  spleen  palpable;  liver  very 
much  enlarged;  colon  distended,  tympanitic  on  percussion;  muscles  of  e.xtremitiea 
very  flabby;  bones  very  small;  epiphyses  of  long  bones  verj^  much  enlarged;  tongue 
coated;    throat  normal ;    some  adenoids. 

{Specimen  of  breast-milk  sent  to  chemist  for  examiiialion  showed: — 

Quantity,  about  2  ounces,  or  Of)  cubic  centimeters. 
Reaction  slightly  alkaline. 

Specific  gravity   1  03105 

Fat    1.22 

Sugar    7.07 

Protcids      0.98 

Shows  low  fat  and  low  protcids. 

The  baby  weighed  about  4  '/a  pounds  at  birth,  and  weighed  between  12  and  13 
pounds  when  (i  months  old.     It  now  wcigiis  naked  about  IC  pounds. 


ILLUSTRATIVE  I'.OTTLL-FEEDIXG.  145 

From  the  history  I  learned  that  the  mother  menstruated  while  nursing  since 
her  child  was  4  mouths  old.  The  infant's  restlessness  was  evidently  associated  with 
this  condition. 

The  study  of  the  chemical  examination  of  the  breast-milk  which  this  child 
received  easily  explains  the  poor  development,  the  proteids  being  less  than  1  per  cent., 
besides  a  very  low  percentage  of  fat  being  also  partly  responsible. 

Treatment:     Absolute  weaning  from  the  mother's  breast. 

Pure  cows'  milk,  warmed  to  feeding  temperature,  or  about  100°  F.,  G  ounces  to 
l)e  given  at  each  feeding.  Feed  every  four  hours;  strict  observance  of  interval  of 
feeding  and  careful  attention  to  sterility  of  everything  coming  in  contact  with  food 
or  utensils  to  be  used. 

ilt'dication :     One-half  teaspoonful  of  malt-extract  given  three  times  a  day. 

Tliis  food  was  not  well  assimilated,  so  I  ordered  V2  measure  of  peptogenic  milk- 
powder  to  be  added  to  each  fi  ounces  of  raw  milk.  Gradually  heat  in  a  saucepan 
over  a  small  flame  for  fi\e  minutes,  then  heat  more  rapidly  and  boil  for  about  ten 
seconds.  Repeat  every  four  hours.  Prepare  each  bottle  separately.  Do  not  warm 
the  food  a  second  time,  if  the  bottle  is  not  emptied  at  one  feeding. 

ily  record  three  days  later  shows:  Had  a  veiy  good  night.  Better  appetite, 
formerly  took  only  3  to  4  ounces,  now  takes  almost  5  ounces.  Did  not  moan  last 
night. 

]\Iarch  27th:  Child  looks  better;  bowels  moved  twice  naturally,  and  have  a 
yellowish  color,  but  no  curds.     Temperature,  99°  F. ;   pulse,  120;  respiration,  36. 

This  feeding  was  continued  for  about  three  weeks,  and  owing  to  good  results, 
no  changes  were  made. 

This  is  the  mother's  report,  which  I  copy:— 

"April  8th:  Had  a  good  night;  slept  from  10.30  P.ii.  to  6.30  A.M.  continuously. 
Bowels  are  splendid,  yellow;  three  stools  yesterday.  Has  a  slight  irritation  of 
genitals;  seems  to  be  fumbling  with  the  parts."  Examination  showed  vulvitis,  irrita- 
tion due  to  scratching,  slight  eczematous  intertrigo. 

Diet  ordered:  To  continue  raw  milk  modified  with  peptogenic  powder;  in  ad- 
dition thereto  beef-soup  thickened  with  cither  hominy,  sago,  or  farina.  Feed  two 
hours  after  milk-bottle  once  a  day,  preferably  about  noon.  Give  the  child  the  white 
of  a  raw  egg  with  sweetened  water  every  other  day.  Tlie  child  received  soup,  alter- 
nating the  next  day  with  the  white  of  egg,  in  the  following  manner:  — 

Warm   rair  milk,  modified  with   peptogenic.  6  ounces  at  6  a.m. 

Milk,    peptogenic     6  ounces  at  10  a.m. 

Soup,  thickened    6  ounces  at  12  Xoon 

Milk,   peptogenic    6  ounces  at  2  P.M. 

Milk,  peptogenic    6  ounces  at  6  p.  m. 

This  food  was  well  borne;  the  child  gained.  To  improve  the  appetite  1  minim 
of  nux  vomica  was  ordered  three  times  a  day,  before  three  feedings. 

Warm  or  rair  milk,  modified  by  heating  willi  peptogenic  as  directed  above:  — 

Raw  milk,  6   ounces    6  a.  u. 

Raw  milk,  6  ounces   10  x.'si. 

White  of  raw  egg.  sweetened    12  Xoon 

^lilk  with  peptogenic    2  p.  m. 

Milk  with  peptogenic    6  p.  m. 

Malt  extract  was  discontinued  every  other  week  and  an  emulsion  of  codliver-oil 
ordered;  25  per  cent,  of  oil  was  given.  Each  teaspoonful  of  the  emulsion  contained 
2  grains  each  of  glyceropliospliate  of  lime  and  glycero|)hos[)hafe  of  soda. 


146  INFANT  FEEDING. 

May  14th:  We  discontinued  giving  peptogenic  and  simply  gave  the  baby  raw 
milk  waiiiK'd  innnediately  before  feeding.  The  milk  was  thickened  by  giving 
zwieback  and  bread-crumbs.  I  also  ordered  steak- juice,  fed  several  teaspoonfuls  at 
noon  with  some  bread-crumbs  or  cracker-dust,  and  mast-beef  juice.  Also  ordered 
egg-crackers,  bread  and  butter,  and  soup  made  with  niashod  peas  in  which  meat  was 
boiled. 

June  1st:  Somatose  V»  teaspoonful  to  be  stirred  with  milk  or  soup;  repeat 
llie  dose  three  times  a  day.     Also  ordered  raw  apple-pulp  sweetened  with  sugar. 

June  20th:  Discontinued  raw  white  of  egg,  and  gave  half  of  soft-boiled  egg, 
half  of  yolk  and  half  of  white,  followed  by  bottle  of  milk  at  10  a.m. 

Child  now  weighs  19  V2  pounds. 

Treatment  discontinued;  child  went  to  the  sea-shore.  I  did  not  see  the  child 
until  middle  of  September,  three  months  later.  Has  had  summer  complaint;  fui)d 
changed;  dili'erent  milk  used  in  countiy  evidently  the  cause.  Child  now  weighs 
18  V2  pounds.  This  child  i-eceived  pea-soup,  cocoa,  zwieback,  and  Nestle's  food.  I 
ordered : — 

Farina  boiled  in  milk. 

Kice  boiled  in  milk. 

Use  one-half  milk  and  one-half  water. 
V      Boil  one  hour  or  longer. 

Also  some  barley-soup,  afternoon  cocoa,  or  milk,  in  the  following  manner: — 

Milk    4  ounces 

Water   4  ounces 

Granulated  sugar  1  teaspoonful 

Lime-water    1  teaspoonful 


Feed  at  6  a.m. 


Feed  at  10  a.m.,  same  as  above,  also  farina  or  rice  boiled  in  milk. 

Feed  at  12  noon,  soup  made  from  chicken  or  beef  thickened  with  barley. 

r  Milk    6  ounces 

I    Chocolate  or 

Feed  at  2..30  P.M.      ■{    Cocoa    2  teaspoonfuls 

Granulated  sugar   2  teaspoonfuls 

Water  2  ounces 

Avoid  all  hnnps  in  chocolate  by  nibbing  up  with  hot  water  and  gradually 
adding  the  milk.     Heat  over  small  flame  and  stir  well. 

Feed  at  0.30  p.if.,  milk  thickened  with  egg-cracker  or  zwieback. 

This  food  was  well  assimilated,  and  then  the  following  was  added:  Sliced  apple 
in  the  morning;    pudding  made  from  broken  zwieback,  some  milk,  and  yolk  of  egg. 

September  30th:  Shredded  wheat,  oatmeal,  or  farina  with  milk,  was  allowed 
in  addition  to  the  afternoon  cocoa  or  chocolate  feeding  above  ordered.  At  noon 
chicken  bouillon  or  soup,  to  which  yolk  of  raw  egg,  well  beaten,  was  allowed. 

In  October  we  gave  raw  scraped  steak  on  a  soda-biscuit.  Also  ordered  fresh 
vegetables,  stewed  or  mashed  peas,  some  spinach  and  cauliflower,  and  baked  potato 
with  butter. 

Bone-marrow,  1  teaspoonful  three  times  a  day,  was  ordered. 

The  child  made  excellent  progress.  Teeth  appeared,  and  the  child  is  strong, 
well,  and  able  to  walk;  no  physical  defect  is  visible:  inentally  the  child  is  normal, 
and.  indeed,  to  all  appearances  it  is  now  a  normal  child. 


I.  l'"i)imula  I 


ILLUSTRATIVK  BOTTLK-FEEDIXG.  147 

Ca^se  in. — Dyspeptic  Infant.  Jictjiiii  in;/  ('(ireful  Rnttle-feeding^  noiD  Perfectly 
^Yell.  Baby  Douglas  C.  M.,  child  of  a  physician,  was  borii  May  29,  1901.  Weighed 
at  birth  0  pounds.  Was  breast-fed  about  two  months.  Owing  to  swollen  breasts, 
the  milk  suddenly  ceased.  The  child  was  weaned.  Weight,  12  pounds.  Stools 
normal  at  time  of  weaning.  Hand-feeding  with  equal  parts  of  milk  and  water  was 
tried.    As  this  was  not  well  borne,  Mellin's  food  was  given. 

When  first  seen  by  me  the  infant  had  frequent  attacks  of  vomiting;  greenish 
stools,  c^ontaining  curds  and  nuicus.  Cries  with  colicky  pains.  Has  constant  in- 
leslinal  fermentation. 

Infant   at    4   months,   while  sufi'ering   with   colic,   was   given:  — 

Pure  mi]l<:    14  ounces  ~\ 

Barley  water  '  .  ,^ 20  ounces 

(Jraiuilated  sugar    4  teasiX)onfuls 

Unu-water 7  teaspoonfuls 

Mix  the  above  and  divide  into  seven  clean  bottles.  Place  in  a  refrigerator  until 
required.  At  feeding-time  empty  contents  of  a  bottle  into  a  saucepan  and  allow  the 
food  to  come  to  a  boil,  then  immediately  remove  from  heat.  When  cooled  to  feeding 
temperature,  give  it  to  the  baby.     Usual  temperature  is  about  100°  F..  or  l)!ood-heat. 

In  addition  to  the  above  food  prune-water,  made  in  the  following  manner,  was 
ordered  for  thirst:  — 

Fleshy  prunes    1   dozen 

Granulated  sugar    S  teaspoonfuls 

\\'ater    2   ])ints 

]Mi.\-  togetlier  and  boil  for  thirty  minutes.  Strain;  feed  when  cold.  Three  to 
0  teaspoonfuls  can  be  given  at  one  time. 

Fresli  orange-juice,  .3  teaspoonfuls  one  liour  I,>efore  milk-feeding,  once  a  day. 
When  seen  a   few  days  later  it  was  found  that  the  child  had  had,  during  tlie 
day.  live  greenish-yellow  stools,  containing  cheesy  curds. 

Ordered  oleum  ricini.  1  teaspooniul  at  10  a.m. 

Feed  at 1 1.;]0  a.m. 

Feed  at 2.30  r..\i. 

Feed  at 5.30  p.m. 

Feed  at 8..30  p.m. 

If  looseness  continues,  leave  out  sugar  and  substitute  saccluirin,  '/j  grain  to 
each  bottle. 

Folhiwing  dav  ordered:  — 


>  l'\irinula  II 


Milk   20  ounces 

Bavlcy-water 14  ounces 

Sugar   4  teaspoonfuls 

Lime-water     7  teaspt)onfuls 

Mix  the  above  and  divide  into  seven   bottles.     Srahl  cacli  bottle  before  feeding. 


'  Barley-water  is  made  by  adding  1  iieaped  tal)Iespoonfu]  of  prepared  barley  to 
1  quart  of  water.  Boil  half  an  iumr,  and  strain  through  cheese-cloth.  Add  enough 
hot  water  to  yield  a  quart. 


148 


INFANT  FKK])TN(i. 


Infant    cr'wd    and    still    seemed    linni-ry    after    feeding,    and    the    food    was    in- 
creased:— 


lorn.ula  III 


Whole   milk    14  ounces  " 

Gravity  cream    7  ounces 

Sterile  water    20  ounces  i 

Cane  sugar 5  teaspoonfuls 

Mix  the  raw  milk  and  cream  in  a  clean  bottle  and  add  the  water  and  sugar. 
Divide  into  seven  bottles  and  keep  in  a  refrigerator  until  feeding-time.  Keep  bottles 
well  stoppered  with  absorbent  cotton.  Warm  the  bottles  in  liot  water  at  feeding- 
time.     Feed  every  three  hours. 

The  fdl lowing  day  the  ehild  had  no  stool  from  2  A.M  to  10  A.M.  It  seems 
better  satisfied  after  the  bottle,  and  takes  food  greedily. 

Food  clianged  to:  — 

Whole   milk    20  ounces 

Barley-water     14  ounces 

Sugar 4  ounces 

Lime-water    7   teaspoonfuls 

Divide  into  seven  feedings.     Feed  everv  three  hours. 


Formula  IV 


As  the  above  formula  agreed,  I  ordered:  — 

Whole  milk    21  ounces  "^ 

Barley-water     14  ounces  L  Formula  V 

Sugar    4  teaspoonfuls  J 

Scald  the  milk  and  divide  into  seven  feedings.  Feed  every  two  and  three- 
fourths  or  three  hours. 

Gained  one  pound  during  the  week;  has  yellowish  stools  after  each  feeding; 
no  vomiting;     cries  after  feeding;     appears  dissatisfied. 

Changed  feeding  to:  — 

Whole  milk    30  ounces  "> 

Barley-waler     12  ounces  L  Formula  VI 

Saccharin    3  '/o  grains  J 

Divide  into  seven  feedings.  Scald  the  raw  milk  with  hot  barley-water;  then 
put  in  ice-chest  until  feeding-time.     Boil  two  minutes  in  saucepan  before  feeding. 

Stool  after  each  feeding,  yellow,  normal  consistency,  alkaline  reaction.  Child 
does  not  f^leep  well;    seems  hungry.     Food  changed  to:  — 

^^■hole   milk    30  ounces  "^ 

Barley- jelly  '     12  ounces  L  Formula  VII. 

Saccharin    .' 3  '/,  grains  J 

Add  1  teaspoonful  of  cream  to  each  feeding;  discontinue  if  vomiting  or  if 
cheesy  curds  appear  in  stools.     Scald  milk  as  before.     Feed  every  three  hours. 

Child  still  appears  hungry  after  feeding.  Stools  less  frequent.  No  vomiting. 
Has  small,  rose-colored  spots  on  legs  and  face.     Weight,   13  pounds. 


'  To  make  l)arley-jeny  take  2  heaping  tablespoonfuls  of  barley  to  12  ounces  of 
water,  boil  down,  and  again  add  enough  water  to  make  12  ounces. 


ILLUSTRATIVE  BOTTLE-FEEDING.  149 

Feeding  changed  to: — 

Milk    42  ounces  ") 

^  „  ;-    Foraiula  VIII 

Cream   2  ounces  t 

Divide  into  seven  bottles  and  feed  every  three  hours. 

If  food  does  not  agi'ee  add  1  teaspoonful  of  Fairchild's  pcptogenic  milk-powder 
to  each  bottle  and  heat  for  three  minutes  before  feeding. 

Ordered  two  doses  of  calomel;     Vio  grain  given. 

Child  appears  very  briglit.  Has  yellowish  stools,  no  colic  j  abdomen  not  dis- 
tended.    No  evidence  of  vomiting.     Sleeps  well  all  night. 

Feeding  changed  to: — 

Milk    4B  ounces  "^ 

Cream    4  ounces  v  Formula  IX 

Dextrinized   wheat    7  teaspooiifuls    J 

Sweeten  and  heat  as  before.     Divide  into  seven  bottles. 

To  make  dextrinized  wheat  take  3  pounds  of  plain  wheat  flour,  boil  in  a  bag 
for  five  houi's,  then  dry  in"  the  oven,  break  open,  reject  the  rind,  and  grate  into 
powder. 

C.'iild    did    not    digest    the   dextrinized-wlieat    feeding.       Changed    to   pure    milk. 
Child  now  takes  pure  milk,  5  to  6  ounces. 

To  relieve  eczematous  excoriation  on  buttocks,  ordered: — 

IJ  Calamin    3.0 

Zinc  oxide  alb 3.0 

Lanolin  or  cold  crcaiu 30.0 

Apply  t.  i.  d. 

Child  does  not  sleep  well  at  night.  Ordered  milk  steamed  in  double  boiler 
for  twenty-five  minutes.  Child  cried  very  much  during  the  last  few  days;  had  thin, 
yellowish  stools  after  each  bottle. 

To  relieve  thin,  watery  stools  ordered:  — 

R  Acid.  HCl    dilut 2.0 

Essence  of  pepsin (iU.U 

Sig. :     Teaspounfiil  three  times  a  day  befdre  feeding. 

Owing  to  an  eczema  on  the  buttocks  after  applying  the  salve,  ordered  e(|ual 
piirts  of  pulverized  zinc  oxide  and  talcum  dusted  over  salve  on  buttocks. 

For  tlie  loose  bowels  tlie  rectum  and  colon  irrigated  witli  '/-  pint  of 
chamoiiiiie  tesi,  to  which  was  add  d  10  grains  of  tannic  acid.  Temperature  of  irri- 
gation, about  105°  F. 

Oleum  ri^ini,  1   teaspoonful,  intcnuilly. 

Changed  feeding  to: — 

Milk    4  ounces  ") 

Barley-water    1  Va  ounces  v    Fornuila  X 

Arrowroot  1   lu  aped  teaspoonful  ) 

Boil,  and  feed  every  three  or  three  and  one-half  hours,  alternating  with  thick- 
ened rice-soup  or  rice-water,  4  to  0  ounces  at  one  feeding.  Baby  did  very  well  on 
this  diet,  a.ssimilated  the  food,  and  gained  in   weight.      Had  one  or  two  yellowish, 


150 


INFANT  FEEDING. 


well  digested  stools  daily.      After  this  iniproveiuent  I  oidored  soups   and  white  of 
egg. 

The  cliild  weighed,  at  six  months,  18  pounds.  The  child  is  perfectly  well,  walks 
and  talks,  and  is  now  in  his  second  year,  with  normal  dentition. 

Materna  Home  Modifier. — This  is  a  glass  apparatus  for  the  modification 
of  cows'  milk  at  home,  and  consists  of  a  glass  vessel  with  pouring-lip,  shaped 
like  a  graduate,  holding  16  ounces.  The  outer  surface  is  divided  by  vertical 
lines  into  seven  panels;  one  panel  shows  the  ordinary  ounce  graduation; 
the  six  others  show  six  different  formula^,  so  arranged  as  to  be  suitable  for 
the  entire  first  year's  feeding.  The  accompanying  diagram  is  a  more  or  less 
accurate  reproduction  of  the  arrangement  of  these  panels. 


Fig.  4i.— Materna  Hume  M(jdifier. 


It  is  possible  to  obtain  other  percentages  than  those  shown  on  the 
panels,  by  mixing  what  is  called  for  by  two  adjacent  formuhe;  as,  for  in- 
stance, ec[ual  quantities  made  according  to  Formulae  1  and  2  combined  will 
give :   fat,  2  V4  per  cent. ;   protcids,  0.7  per  cent. ;   sugar,  6  per  cent. 

As  may  readily  be  seen,  all  the  formula)  call  for  the  same  ingredients, 
excepting  the  sixth,  which,  instead  of  water,  requires  barley  gruel,  and 
granulated  sugar  in  place  of  milk  sugar. 

The  method  of  using  the  apparntns  is  extremely  simple.  Having  de- 
cided upon  the  formula  to  be  used,  that  panel  is  to  be  observed  to  the  ex- 
clusion of  all  the  others.  The  respective  ingredients  are  then  poured  into 
the  vessel,  to  the  line  below^  the  designated  sul)sl;ance.  Thus,  milk  sugar  is 
put  in  first  (or,  in  its  aijsencc,  granulated  ;  and  the  line  with  the  cross 
shows  to  what  point  the  latter  should  be  used),  then  the  water,  lime-water. 


HOME  MODIFICATION. 


151 


cream,  and  milk  in  the  order  shown.  The  whole  is  then  stirred,  and  the 
result  will  be  a  milk  whose  formula  is  at  the  top  of  the  panel.  The  milk 
used  with  the  apparatus  should  be  good  average  milk.  The  cream  should  be 
the  light  centrifugal  cream  as  obtained  in  bottled  milk  (16-20  per  cent.). 
The  water  should  be  hot,  to  dissolve  the  sugar.  The  barley  gruel  should  be 
prepared  in  the  usual  way  with  Eobinson's  or  ordinary  barley. 

According  to  the  age  and  size  of  the  child,  the  vessel  must  be  filled 
once,  twice,  or  three  times  to  obtain  the  quantity  requisite  for  the  twenty- 


1. 

3d-14th  Day. 

Fat  2^. 

Proteids,  0.6;4. 

Sugar,  6j(. 

2. 

2d-6th  Week. 

Fat,  V/^i,. 
Proteids,  O.SjJ. 

Sugar,  6j(. 

3. 

6-11  th  Week. 

Fat,  Zi,. 

Proteids,  lj(. 

Sugar,  65(. 

4. 

11  wk.-5  mo. 

Fat,  Si^'*. 

Proteids,  \y^i. 

Sugar,  1% 

5. 

5th-9th  month. 

Fat,  i$. 

Proteids,  2^. 

Sugar,  1% 

6. 

9th-12th  month. 

Fat,  %y^. 

Proteids,  2J^ 

Sugar,  3J^ 

Milk 

Milk 

Milk 

Milk 

Milk 

Milk 

Cream 

Cream 

Cream 

Cream 

Cream 

Lime-water 

Lime-water 

Water 

Water 

Water 

Lime-water 

Milk-sugar 

Lime-water 

Milk-sugar 

Water 

Water 

Cream 

Milk-sugar 

Milk-sugar 

Barley-gruel 

Milk-sugar 

Gr.  sugar 

four  hours'  feeding.  The  pouring  into  bottles  and  sterilization  are  then  done 
as  usual.  Full  directions,  including  a  schedule  for  the  twenty-four  hours' 
feeding  at  the  various  periods  of  the  child's  growth,  accompany  the  appa- 
ratus, which  is  simple,  accurate,  and  economical,  making  properly  modified 
milk  of  practical  value  obtainable  in  places  where  it  has  hitherto  been  im- 
possible to  get  it. 

The  materna  is  adapted  for  home  use  only  when  the  physician  notes 
results.  To  intrart  an  apparatus  of  this  kind  into  the  hands  of  a  mother 
or  nurse  not  conversant  with  the  difference  in  the  percentage  of  fat  contained 
in  cream  is  not  only  wrong,  but  will  prove  disastrous  to  the  infant  so  fed 
before  many  weeks  are  over.    The  author  recently  saw  a  case  of  dyspepsia 


152 


INFANT  FEEDING. 


brought  about  l)y  footling  in  this  caroless  uinnncr.  On  iho  otlior  hand,  the 
apparatus  will  serve  as  a  guide  to  those  physicians  whose  training  in  per- 
centage-feeding requires  occasional  assistance. 

A  very  practical  "milk  modifying  gauge"  devised  by  Mitchell  has  been 
placed  on  the  market.  It  can  be  procured  from  the  National  Drug  Coui- 
pany  of  Philadelphia.  It  is  designed  to  aid  those  unfamiliar  with  h.omc 
modification,  and  is  especially  valuable  to  those  distant  from  large  cities 
with  laboratories. 


Fig.  45— ilitchell's  .Mil,-:    .\iudit'yiiig  Gauge. 


Taiu.e  No.  29. 
DlKT  FOI!  A   ClIILU  F1!U.\1   (JSE    Yi;.\|;TO   FlFTKKN   ^loNTIlS.'' 


5  A.M.     Orange  juice, 

Apple  sauce,  or 
Pnino  jelly.. 

6  A.M.     Milk,    8    ounces,    with    zwie- 

back or  crackers. 

10        A.M.     Milk,  8  ounces. 

12.30  P.M.     Beef  or  chicken  soup,  thick- 
ened with  toast  crumbs,  or 


12.30  v.M.  E.vpic'sscd  steak  juii-e  or 
beef  blood,  with  toa^t 
crumbs. 

3  r.M.  Milk,  8  ounces,  with  soda 
bi.-;cuit. 

5        P.M.     Apple  sauce. 

6.30  P.M.     Milk,  8  ounces. 


'  Jn  the  chapter  on  "Weaning,"  I  have  already  described  in  detail  another  mctlnul 
of  substitute  feeding  for  a  child  about  I  year  old. 


DIET  FOR  A  CHILD  FROM  ONE  AND  ONE-HALF  TO  TEN  YEARS.      153 


Table    No. 
Diet  for  a  Child  fko:\i  Eigiiteex 

G.30  A.M.     Orange  juice. 

Apple  sauce,  or 

Prune   jelly. 
7.30  A.M.     Warm  milk,  8  ounces; 

Mellin's  Food,  1  ttaspoon,  or 

Eskay's  Food,  1  teaspoun; 

Zwieback  or  crackei',  with 
butter. 
11  A.M.     Farina, 

Hominy, 

Cream  of  wheat, 

Oatmeal,  or 

Grape-nut,  scalded  with  liot 
milk ;  in  addition,  a  cuj)  of 

^^'arm  milk.  0  ounces. 
2  P.M.     A  soup,  a  meat,  a  vegetable, 
and  a  cracker. 

Reef  or  chicken  soup,  thick- 
ened with  split  peas,  sago, 
rice,  or  farina. 

Drink  of  water. 


30. 

Months  to  Three  Years. 

2  P.M.  Clear  broth,  with  yolk  of 
egg,  or  one  or  more  ounces 
of  expressed  beef  blood. 

Oyster  or  clam  broth. 

Joint  of  chicken, 

Broiled  halibut. 

Raw  scraped  steak, 

Chicken  jelly,  or 

Calfs-foot  jelly    (without 
wine   tiavor ) . 

Raketl  potato,  with  butter; 

Spinach,  or 

Carrots. 
G  I'.M.     Crust  of  bread  or  zwieback. 

Warm  milk,  with  white  of 
egg;  or 

Cocoa. 

Junket,  custard,  corn  starch, 
tapioca,  or  farina  pudding, 
a  few  teaspoonfuls. 


Diet  for  a  Child  from  Three  to  Ten  Years. 

A  child  of  3  years,  excepting  in  rare  instances,  sliould  not  be  fed  oftener 
tlian  three  times  a  day.  The  best  time  for  feeding  is :  morning  meal,  7  to 
8  A.M.;  noon  meal,  12  to  1  p.m.,  and  evening  meal,  5.30  to  6.30  p.m. 

In  rare  instances  fruit  or  a  cnp  of  milk  may  be  allowed  between  the 
noon  and  evening  meal,^  In  the  majority  of  cases  five  hours  are  required 
to  fully  digest  the  food  given. 

The  morning  meal  should  consist  of  a  fruit,  a  small  dish  of  cereal  with 
cream,  a  cup  of  milk,  and  a  piece  of  toast  or  crackers. 

The  noon  meal  should  consist  of  a  plate  of  soup,  a  small  portion  of  meat, 
a  small  potato,  a  vegetable,  bread,  or  crackers,  or  stale  sponge  cake,  water. 

The  evening  meal  should  consist  of  an  egg  or  pudding,  a  cup  of  cocoa 
or  milk,  crackers  or  bread  with  butter  or  honey. 

It  is  safer  to  give  a  light  meal  in  the  evening  rather  than  load  the 
stomach  with  heavy  food.  The  American  custom  of  eating  dinner  at  night 
should  not  be  applied  to  children. 

That  milk  is  very  absorptive  is  well  recognized.  It  is  a  bad  precedent 
to  store  it  away  in  refrigerators,  unless  it  is  placed  in  sealed  jars,  apart 
from  foods  which  exude  odor. 


'Horlick's  Food  Co.  make  a  malted  milk  lunch  tablet,  coated  with  chocolate, 
that  is  nutritious  and  digestible.  They  are  especially  indicated  when  small  meah 
should  be  given. 


154 


INFANT  FEEDING, 


Selection  can  be  made  from  the  following  dietary: — 

Table  No.  31. 


MOKNING    WEAL. 


Fruit — ■ 

Raw,  stewed,  or  baked  apple. 

Grapes. 

Grape  fruit. 

Oranges. 

Cherries. 

Peaches. 

Banana. 

Stewed  prunes. 
Cereals — ■ 

Hominy. 

UatmeaL 

Farina. 

Force,  or 

Wheat  Flake  Celery  Food. 


Cereals — ■ 

Shredded  wheat. 

Cream  of  wheat. 

Wheaten  grit. 

Arrow  root. 

Cerealine. 

Yellow  Indian  meal. 

"Wliite  indian  meal. 

Wheat  flakes. 
Buttered  toast. 
Albert  cakes 
Zweiback. 

Vienna  bread  and  butter. 
Stale  sponge  cake. 
Lady  fingers. 


NOON   MEAL. 


Meat   or   chicken    soup,   thickened    with 

lentils,  peas,  split  peas,  sago,  farina, 

rice  or  egg. 
Meat— 

Broiled  chop,  steak,  or  fish. 

Chicken. 

Stewed  tripe. 

Sweet-bread. 

Raw  scraped  beef. 

Roast  beef. 


Meat — 
Lamb. 
Bone  marrow. 

Baked  or  mashed  potatoes,  spinach, 
peas,  beans,  tomatoes,  cauliflower,  car- 
rots, asparagus,  rhubarb,  cranberries, 
or  celery. 

Apple  cider,  buttermilk,  kurayss,  seltzer, 
lemonade,  or  very  weak  tea. 


EVENING   MEAL. 


Crackers  and  milk. 

Custard. 

Cornstarch  pudding. 

Com  muffins. 

Farina  pudding. 

Milk  toast. 

Tapioca  pudding. 

Chicken  jelly  without  wine. 


Calf's-foot  jelly  without  wine.  ■ 

Junket. 

Oysters. 

Boiled,  scrambled,  or  poached  eggs. 

Cream  of  barley. 

Cream  of  rice. 

Cocoa  and  milk. 

Toast  or  crackers. 


Articles  of  Food  Which  Should  be  Forbidden  Until  After  the  Tenth  to 
Twelfth  Year. — Fruit:  All  dried  fruits  (with  the  exception  of  i)runes),  pre- 
served fruits,  fruits  out  of  season,  over-ripe  fruits  or  under-ripe  fruits. 

Meats. — Pork,  ham,  hacon,  sausages,  kidneys,  duck,  and  goose. 

Ycgetahtes. — Cabbage,  onions,  radishes,  cucumbers,  turnips,  and  egg 
plant. 

Drinks. — Coffee,  tea,  and  ice  cream  soda. 

All  candies,  cakes,  nuts,  i)ies,  and  salads  must  be  forbidden. 


DEXTRINIZED  FOOD.  155 

Feeding  of  Delicate  or  Sick  Children. 

Infants  having  weak  digestion  or  dyspeptic  infants  require  modification 
of  the  casein  in  the  milk.  In  such  cases  the  milk  should  be  prepared  or 
predigestcd.  Sometimes  dextrinizing  the  food  will  so  thoroughly  break  up 
the  curd  of  the  milk  and  render  it  so  finely  flocculent  that  it  will  be  much 
better  adapted  for  a  subnormal  stomach. 

Method  of  Dextrinizing. — Prepare  the  wheat,  barley,  oatmeal,  or  rice 
fiour  by  adding  a  tablespoonful  of  the  same  to  a  pint  of  water,  adding  a 
pinch  of  salt,  and  boiling  the  same  for  from  fifteen  minutes  to  one  hour. 
This  will  make  a  gelatinous  solution,  and  hence  the  name  of  barley  jelly, 
rice  Jelly,  oatmeal  jelly,  or  wheat  jelly.  We  allow  this  jelly  to  cool,  and 
when  cool  enough  to  be  tasted  we  can  add  a  diastase,  such  as  cereo ;  or  taka- 
diastase,  made  by  Parke,  Davis  &  Co. ;  or  the  Forbes  diastase.  When  a 
small  quantity  of  this  diastase  is  added  to  the  jellies  above  mentioned,  they 
lose  their  thickness,  and  become  very  thin.  They  can  easily  be  strained 
through  cheese  cloth,  and  some  water  added  to  make  up  for  the  loss  by 
evaporation  during  the  boiling.  This  jelly,  or  gruel,  as  it  is  sometimes  called, 
made  from  either  barley,  rice,  wheat,  or  oatmeal,  is  to  be  used  with  the 
milk  after  the  diastase  is  added.  In  certain  diseases,  where  milk  is  not  well 
borne,  such  as  dyspepsia  (dyspeptic  vomiting)  or  in  summer  complaint, 
where  the  giving  of  milk  is  prohibited,  feeding  the  dextrinized  gruels  for 
several  days  will  be  found,  not  only  very  useful,  but  very  healthful.  In 
making  this  dextrinized  gruel,  small  particles  will  be  seen  floating,  which 
settle  out  upon  standing.  These  particles  consist  of  the  cell  walls  and  the 
proteids  of  the  cereal,  and  cut  the  curds  of  the  milk  into  fine  pieces, 
when  the  curds  begin  to  shrink  under  the  combined  action  of  rennet  and 
acid.  In  using  this  diastase  we  aim  at  breaking  up  the  tough  curd  in  cows* 
milk  by  purely  mechanical  means. 

Homemade  Diastase  for  Dextrinizing  Food. — Henry  D.  Chapin*  de- 
scribes a  simple  decoction  of  diastase  made  as  follows:  "A  tablespoonful 
of  malted  barley  grains  is  put  into  a  cup,  and  enough  cold  water  added  to 
cover  it,  usually  two  tablespoonfuls,  as  the  malt  quickly  absorbs  some  of 
the  water.  This  is  prepared  in  the  evening  and  placed  in  the  refrigerator 
over  night.  In  the  morning  the  water,  looking  like  thin  tea,  is  removed 
with  a  spoon  or  strained  off,  and  is  ready  for  use.  About  a  tablespoonful  of 
this  solution  can  be  thus  secured,  and  is  very  active  in  diastase.  It  is  suffi- 
cient to  dextrinize  a  pint  of  gruel  in  ten  to  fifteen  minutes." 

During  the  summer,  in  the  critical  cases  of  summer  complaint  in 
which  subnormal  digest'on  existed,  the  author  has  seen  very  good  results 
follow  the  administration  of  any  and  all  of  the  malt  extracts  now  in  our 
market.    Frequently  the  administration  of  a  half-teaspoonful  of  malt  extract 

*  Journal  of  the  American  Medical  Association,  July  14,  1900. 


156  INFANT  FEEDING. 

to  an  infant  immediately  before  feeding  was  not  only  relished  by  the  infant 
on  account  of  the  pleasant  taste  of  the  malt,  but  certainly  aided  in  the 
assimilation  of  the  food.  Earely  was  more  than  three  teaspoonfuls  of  malt 
ordered  during  twenty-four  hours.  Such  preparatiwis  as  maltine  give  very 
good  results.    The  malt  extract  has  a  very  pleasant  flavor  and  is  well  borne. 

Frequently,  when  expense  proved  an  important  item,  sufficient  dex- 
trinization  of  foods  could  be  procured  with  these  malt  preparations  above 
cited. 

It  is  claimed  by  some  that  most  malt  preparations  deteriorate  on  stand- 
ing or  if  exposed  too  long;  this  is  certainly  untrue. 

Substitute  Feeding. 

Gastric  disturbances  such  as  vomiting  or  diarrhoea  contraindicate  the 
use  of  milk.  When  colic  follows  the  use  of  milk  we  are  frequently  com- 
pelled to  discard  milk  until  such  acute  symptoms  subside.  If  a  child  has 
large  or  small  cheesy  curds  in  the  stool  and  does  not  gain  in  weight,  then 
the  food  is  improper. 

During  acute  infectious  diseases,  such  as  scarlet  fever,  diphtheria,  or 
typhoid  fever,  we  are  compelled  to  reduce  the  proteid  element  owing  to  its 
lack  of  assimilation. 

The  food  indicated  is  one  that  is  very  nutritious  and  easily  digested, 
such  as  whey  or  sweet  almond  milk  (see  dietary).  If  the  child  is  1  year 
or  older,  soup  thickened  with  split  peas  or  beans,  a  chicken,  mutton,  or 
veal  broth  may  be  fed  in  three  or  four  hourly  intervals.  Soup  thickened 
with  toasted  bread  crumbs  may  also  be  given. 

For  a  Baby  Under  One  Year. — When  the  symptoms  previously  described 
are  present  in  an  infant  and  milk  must  be  stopped,  trophonine,  made  by 
Eeed  &  Carnrick,  in  teaspoonful  doses  every  hour,  is  a  valuable  substitute. 
Whey  is  also  indicated. 

In  acute  milk  infection  and  sumnior  complaint,  during  my  summer 
service  at  the  Riverside  Hospital.  1  liave  seen  eliildren  retain  trophonine 
when  food  containing  the  slightest  trace  of  milk  was  rejected. 

I  have  frequently  used : — 

Nestle's  Food 2  teaspoonfuls 

Water    8  ounces 

Warm  in  saucepan  until  it  l)oils.     Feed  3,  4,  or  5  ounces  every  few  hours. 

Feeding-bottles. 
A  proper  feeding-bottle  is  one  that  has  no  corners  or  angles  on  the 
inner  surface.     The  bottom  should  be  rounded  so  that  every  part  of  the 
same  can  be  properly  cleaned.     Bottles  that  have  corners  and  grooves  will 
harbor  bacteria. 


FEEDING-BOTTLES. 


15/ 


]\Iy  preference  has  ahvaj's  been  for  two  kinds  of  l)ottIes:  1.  Those 
holding-  4  ounces  and  graduated  on  one  side  in  both  ounces  and  tablespoons; 
this  saves  much  time  and  troiible.  2.  Bottles  holding  8  ounces  and  divided 
off  into  1()  tablespoonfids  or  8  equal  ounces. 

Exactness  of  Ounces. — It  may  not  he  out  of  place  to  ask  each  physician 
to  insist  on  having  the  graduated  oiinces  on  an  infcint's  feeding-bottle  meas- 
ured with  an  (icciiraic  (jnuJiidtc.  obtainal)le  at  every  drug  store.  In  many 
instances  the  author  noted  feeding-bottles  wherein  the  ounces  indicated 
were  very  uiu'((ual,  and  one  particular  bottle,  graduated  to  8  ounces,  held 
\'l  ounces. 


Fig.  46.  Fig.  47. 

Fig.  46. — Author's  Choice  of  Feeding-bottle. 

Fig.  47. — Bottle  Warmer.  A  convenient  bottle  wanner,  adapted  for 
keeping  the  night  feeding  warm,  is  here  illustrated.  It  is  made  by  the 
Arnold  Sterilizer  Co.    It  is  also  useful  when  traveling. 


Long  Iluhhrr  Tides. — ]\Iost  ])rominent  pediatrists  agree  that  the  long 
rubber  tubes  are  a  convenient  })lace  for  harboring  uiicro-organisms,  and  they 
ha\c'  been  universally  condemned. 

Care  of  the  Bottle. — Evei-y  bottle  should  l)e  tlioroughly  cleaned  with 
a  brush  and  a  sohition  of  baking  so(hi  and  watei",  a  teaspoon  of  soda  to  a 
pint  of  water.  The  bottles  must  then  be  thoroughly  rinsed  with  clear  water. 
If  )nilk  has  fermented  or  if  some  residue  adheres  to  the  bottle  and  the  same 
cannot  be  j)r()perly  cleaned,  then  boiling  the  bottles  will  be  necessary.  In 
general  and  for  daily  use  the  bottle  need  not  l)e  boiled  every  day. 

Proper  Time  for  Cleaning  lloUlrs. — The  best  lime  to  clean  a  l)ottle  is 
immediately  after  the  baby  has  been  fed;  this  lu'events  Ihe  food  souring- 
in  the  bottle,  and  it  is  veiT  easily  cleaned. 

Tlie  hoifle  hri(s]i  has  a  long  handle  and  bristles  foi'  cleansing  the  bottles. 
This  l)rush  should  be  used  before  the  bottles  are  p'ut  into  the  soda  solution. 


15S 


INFANT  FEEDING. 


It  is  understood  that  the  brush  can  itself  harbor  bacteria  and  particles  of 
milk  removed  while  cleansing.  It  is  therefore  understood  that  the  brush 
must  be  thoroughly  boiled  in  a  soda  solution  after  each  use. 


Bottle-brush. 


Choice  of  a  nipple  is  another  important  matter.  My  preference  has 
always  been  for  a  black-rubber  nipple,  and  it  is  a  very  wise  point  to  use  a 
nipple  no  longer  than  one  week;  in  other  words,  old,  worn  nipples  are  useless 
for  the  proper  management  of  infant-feeding.  Black  rubber  is  softer  than 
white  rubber;  most  white  rubber  is  supposed  to  contain  lead;  hence  a 
decided  reason  for  not  using  it. 

Nipples  Eecommended. — One  of  the  best  nipples  made  is  the  so-called 
anticolic  nipple.  This  nipple  has  a  ball-shaped  top,  which  enables  a  baby 
to  take  a  firm  hold;  it  has  three  small  holes,  which  give  an  easy  flow  of. 
milk,  and  regulate  a  slow  meal.  Nipples  having  very  large  openings,  which 
will  permit  a  baby  to  finish  a  6  or  8-ounce  bottle  of  food  in  five  or  six  min- 
utes, are  useless,  and  this  gulping  of  food  is  really  the  cause,  or  one  of  the 
causes,  of  infantile  colic. 


Fig.  49. — Anticolic  Nipple. 

I  have  used  another  nipple,  but  it  is  much  harder  to  clean,  and  unless 
all  precautions  for  sterilization  are  carefully  noted  it  should  not  be  used; 
yet,  in  the  hands  of  the  intelligent  or  where  mo  have  a  trained  nurse,  it  can 
be  safely  recommended.  It  is  called  the  "Mizpah."  This  nipjjle  has  also 
a  very  small  puncture,  so  that  the  baby  gets  the  food  sloAvly. 

The  "swan-bill"  ni]t])lc  aiul  tlie  long  French  nipple  I  also  like.  I  have 
noted  just  as  good  results  as  with  the  above-mentioned  kinds. 


STKPJLTZATIO.X   OF  .MILK. 


159 


VtntilafnJ  yipple. — A  ni])])le  vevv  highly  spoken  of  is  the  ventilated 
nipple  made  l)y  Ware,  of  Philadelphia,  which  has  a  small  opening  or  valve 
on  the  side,  and,  as  the  milk  is  drawn  in  from  the  bottle,  it  permits  air  to 
(liter,  thus  preventing  a  vacuum  from  being  formed.  It  is  also  supposed  to 
be  non-collapsible,  and  is  highly  recommended  by  those  who  have  used  it. 
The  only  objection — already  offered — is  that  all  nipples  must  not  only  be 
j)racti(al  for  use,  but  must  l)e  capable  of  thorough  sterilization. 

Cleaning  the  Xipplrs:. — The  ])r('venti()n  of  stomatitis  and  mouth  affec- 
tions d{'])ond  upon  proper  hygiene  of  the  nip])le.  It  docs  not  require  much 
time  or  trouble  to  remove  the  iii|ipK'  I'l^om  a  liotth'  and  flimir  11  mln  Jjaihii;/ 
irtilcr  iiii iiicdidlHij  after  iisinij.  l>oracic  acid  or  common  salt  may  be  added 
to  the  boiling  water.     A  ni])]de  thus  treated  is  properly  sterile. 

The  ni])ple  sterilizer  (see  Fig.  •-)<•)  is  a  very  convenient  little  arrange- 
ment made  by  Ware,  of  rhiladel})hia.  It  serves  the  purpose  admirably  for 
the  sterilization  of  nipples. 


Fig.    50. — Nipple-sterilizer. 


Sterilization  of  Milk. 

When  Soxhlet  first  announced  the  method  of  sterilization,  he  awoke  the 
profession  to  the  realization  of  the  dangers  lurking  in  crude  cows'  milk. 
His  aim  was  to  destroy  pathogenic  l)acteria,  and  give  the  infant  a  milk 
which  did  not  contain  living  l)acteria. 

In  order  to  sterilize  milk  accordingly  to  Soxhlet,  we  must  heat  milk 
to  a  temperature  of  212°  F.  and  continue  tliis  steaming  for  thii'ty  minutes. 
We  know  that  heating  milk  produces  many  changes,  some  of  which  are 
not  tboi'oiighly  understood.     Other  changes  have  been  positively  proven. 

Changes  in  Milk  Caused  by  Sterilization. — In  some  experiments  made 
by  Dr.  E.  :\I.  lliesiand  and  i)iil)lished  by  Dr.  B.  C.  Hirst,^  it  was  found  that 
by  sterilization  : — 

1.  The  allium  in   is  coagulated. 

2.  Casein  is  less  readily  precipitated  l)y  rennet  than  in  normal  milk. 

3.  Fat  is  freed  to  a  slight  extent;  fat  not  freed  has  a  lessened  tend- 
cncv  to  coalesce. 


1  Medical  Xows,  Janunrv  HI,  ISOl. 


160  INFANT  FEEDING. 

4.  Sugar  undergoes  some  change,  as  shown  by  its  lessened  dextrorota- 
tory power. 

The  considerations  suggested  by  the  foregoing  facts  are: — 

1.  The  coaguhition  of  milk-albumin  by  sterilization  may  render  tlie 
milk  more  difficult  of  digestion. 

2.  Sterilization  interferes  with  the  coagulability  of  milk  by  rennet, 
and  presumably,  therefore,  with  its  digestibility  by  the  gastric  juice, 

3.  Free  fat,  as  found  in  sterilized  milk,  is  probably  not  readily  assimi- 
lated in  infant  food.  The  fat  not  free,  being  inclosed  in  a  less  easily 
destructible  envelope,  is  probably  slow  of  digestion.^ 

On  the  question  of  sterilized  milk  the  weight  of  evidence  seems  to  show 
that  the  process,  while  preventing  undue  fermentation  so  changes  certain  of 
the  natural  ferments  and  some  of  the  fats  that  the  milk  is  less  easily  digested 
and  less  nutritious.^ 

The  sterilization  of  milk  is  advocated  chiefly  to  destroy  pathogenic 
bacteria.  The  profession  has  been  educated  to  the  belief  that  we  must  kill 
all  living  micro-organisms  in  food. 

When  the  method  was  first  advocated,  the  profession  adopted  it  in  all 
parts  of  the  world;  so  that  thousands  of  babies  have  been  brought  up  on 
sterilized  milk.  Within  the  last  few  years  sentiment  has  changed.  Steril- 
ization accomplishes  the  destruction  of  pathogenic  bacteria,  but  it  also  pos- 
sesses certain  disadvantages. 

The  spores  of  pathogenic  bacteria  cannot  be  destroyed  by  the  ordinary 
process  of  sterilization. 

To  properly  sterilize  milk  it  is  necessary  to  subject  it  to  the  process  of 
tynddllization.  This  will  render  milk  germ-free.  This  latter  process  con- 
sists of  subjecting  the  milk  to  the  process  of  sterilization  for  at  least  twenty 
to  thirty  minutes  on  three  successive  days.  For  practical  purposes  it  is 
useless. 

The  chemical  changes  produced  in  milk  by  the  process  of  sterilization 
are  as  follows:  The  lactalbumin  coagulates  at  a  temperature  of  160°  F. 
(70°  C).  Thus  the  temperature  being  212°  F.  renders  this  ingredient 
decidedly  different  from  what  it  appears  in  its  raw  state;  the  casein  is 
rendered  less  coagulable  by  rennet  and  appears  to  be  acted  upon  more  slowly 
both  by  pepsin  and  trypsin;  the  organic  phosphorus  is  changed  into  an 
organic  phosphate;  citric  acid  is  partially  precipitated  as  calcium  citrate, 
and  some  lime  salts,  which  are  usually  soluble,  are  converted  into  insoluble 
compounds. 

Certain  changes  also  occur  in  the  fat.  Moreover,  certain  natural  fer- 
ments in  fresh  milk,  belie^ed  to  be  of  value  in  digestion,  are  destroyed  by 
heat. 


•Medical  Record,  February  28,  1891. 

•North  American  Practitioner,  June,  1892,  from  the  "Year-book  of  Treatment" 
(Lea  Brothers  &  Co). 


STERILIZED  MILK.  161 

Many  of  these  changes  are  but  imperfectly  understood,  and  some  of 
them  are  doubtless  without  any  injurious  effect  upon  nutrition.  There  is, 
however,  one  important  clinical  reason  for  believing  that  the  nutritive  prop- 
erties of  milk  are  impaired  by  heating  to  212°  F.,  viz.,  the  occurrence  of 
scurvy  in  infants  who  are  fed  upon  such  milk  for  a  long  time  (Holt), 

We  know  that  a  great  many  children  fed  on  sterilized  milk  develop 
scurvy.  The  same  is  true  of  children  fed  on  boiled  milk.  The  reason  is, 
Eundlett  so  ably  says:  "Changes  take  place,  not  in  the  albumin,  fat,  nor 
sugar,  but  in  the  albuminate  of  iron,  phosphorus,  and  possibly  in  the  fluorine, 
vital  changes  take  place.  These  albuminoids  are  certainly  in  the  milk,  de- 
rived as  it  is  from  tissues  that  contain  them,  and  are  present  in  a  vitalized 
form  as  proteids."  On  boiling,  the  change  taking  place  is  simply  due  to 
the  coagulation  of  the  globulin,  or  proteid  molecule,  which  splits  away  from 
the  inorganic  molecule,  and  thus  renders  it,  as  to  the  iron  and  fluorine, 
unabsorbable  and,  as  to  the  phosphatic  molecule,  nnassimilable.  This  is 
the  change  that  is  so  vital,  and  this  only  takes  place  when  milk  is  boiled. 

It  is  evident  that  children  require  phosphatic  and  ferric  proteids  in 
a  living  form,  which  are  only  contained  in  raw  milk. 

Cheadle  says  that  phosphate  of  lime  is  necessary  to  every  tissue;  no 
cell  growth  can  go  on  without  earthy  phosphates;  even  the  lowest  form  of 
life — such  as  fungi  and  bacteria — cannot  grow  if  deprived  of  them.  These 
salts  of  lime  and  magnesia  are  especially  called  for  in  the  development  of 
the  bony  structures. 

Avoidance  of  Scurvy. — Since  clinical  experience  has  demonstrated  that 
the  prolonged  use  of  sterilized  milk  and  boiled  milk  will  produce  scurvy, 
and  that  improvement  is  immediately  noted  when  raw  milk  is  given,  or 
raw  muscle  juice  (beef-juice)  or  raw  white  of  egg,  added  to  fresh  fruit 
juices,  does  it  not  seem  more  plausible  to  commence  feeding  at  once  with  raw 
milk  rather  than  after  scurvy  or  rickets  is  developed? 

There  is  a  certain  deadness,  or  to  put  it  differently,  absence  of  fresh- 
ness, that  is  lacking  in  milk  that  has  been  boiled  or  sterilized,  just  as  it  is 
the  absence  of  fresh  meats  and  green  vegetables  which  is  known  to  cause 
scurvy  in  the  adult. 

In  my  own  practice  I  have  so  frequently  been  disappointed  in  the  use 
of  sterilized  milk,  that  within  the  last  few  years  I  have  entirely  discarded 
its  use. 

The  Disadvantages  of  Sterilized  Milk  From  a  Clinical  Standpoint. — 
The  first  effect  of  using  sterilized  milk  is  that  the  child  will  be  con- 
stipated. It  is  for  this  reason  decidedly  objectionable.  It  is  wise  to  re- 
member that  one  of  the  earliest  symptoms  of  rickets  is  constipation.  We 
have  known  that  the  prolonged  use  of  sterilized  milk  results  in  rickets. 
The  symptom  of  constipation  should  therefore  be  looked  upon  not  as  a 
temporary,  but  as  a  permanent  damage  to  the  body.     Therefore,  it  should 


162  INFANT  FEEDING. 

not  be  neglected.  Appropriate  dietetic  treatment  can  easily  modify  con- 
stipation. Clinicians  all  agree  that  the  prolonged  use  of  sterilized  milk 
cannot  be  advocated.  There  may  be  individual  children  who  thrive  on 
prolonged  use  of  sterilized  milk,  and  I  dare  say  on  any  form  of  feeding. 
We  are  dealing,  however,  with  average  children,  and  these  all  show  a  cer- 
tain train  of  symptoms. 

Constipation  of  the  most  stubborn  kind  will  be  encountered  in  all 
children  fed  on  sterilized  milk.  This  condition  exists  regardless  of  the 
season  of  the  year.  Children  do  not  thrive  as  well  on  sterilized  milk  as  they 
do  on  milk  subjected  to  a  much  lower  degree  of  temperature.  Sterilized 
milk  is  rendered  less  digestible  than  it  is  in  its  raw  state. 

Freeman^  says  that  the  modifications  produced  in  milk  heated  to  212° 
F.  consists  in  the  starch-liquefying  ferment  being  destroyed;  the  casein 
being  rendered  less  coagulable  and  therefore  being  acted  upon  slowly  and 
imperfectly  by  pepsin  and  pancreatine,  and  the  milk  sugar  being  destroyed. 

Fayel,^  discussing  boiled  milk,  says  that  it  is  more  indigestible,  and 
in  no  respect  safer  than  unboiled  milk.  The  temperature  at  which  it  boils 
is  insufficient  to  destroy  microbes,  and  the  milk  is  therefore  not  sterilized. 
Its  density  is  increased  by  the  boiling,  above  that  suitable  for  infant  diges- 
tion. 

Milk  consists  of  a  multitude  of  cells  suspended  in  serum.  The  cells 
are  fat  cells  which  form  the  cream.  The  remaining  cells  are  nucleated  and 
of  the  nature  of  white  corpuscles.  The  serum  consists  of  water  in  which 
is  dissolved  milk-sugar  and  serum  albumin,  with  various  salts  and  chief 
of  all  casein.  The  cells,  with  the  exception  of  fat  corpuscles  are  all  living 
cells,  and  they  retain  their  vitality  for  a  considerable  time  after  the  milk 
is  drawn  from  the  mammary  glands.' 

There  is  reason  for  supposing  that  when  fresh  milk  is  ingested  the 
living  cells  are  at  once  absorbed  without  any  process  of  digestion,  and  enter 
the  blood-stream  and  are  utilized  in  building  up  the  tissues.  The  casein 
of  the  milk  is  digested  in  the  usual  way  as  other  albuminoids  by  the  gastric 
juice,  and  absorbed  as  peptone.  There  is  also  absorption  of  serum  albumin 
by  osmosis.  The  chemical  result  of  boiling  milk  is  to  hill  all  the  living  cells 
and  to  coagulate  all  the  albuminoid  constituents.  Milk  after  boiling  is 
thicker  than  it  was  before. 

The  physiological  results  are  that  all  the  constituents  of  the  milk  must 
be  digested  before  it  can  be  absorbed  into  the  system;  therefore,  there  is 
distinct  loss  of  utility  in  the  milk,  because  the  living  cells  of  fresh  milk 
do  not  enter  into  the  circulation  direct  as  living  protoplasm  and  build  up 
the  tissues  direct,  as  they  would  do  in  fresh,  unboiled  milk.    In  practice  it 


*  Paper  read  at  Academy  of  Medicine,  New  York,  May  11,  1893. 
•Medical  Age,  September  25,  1893. 

*  J.  L.  Kerr,  British  Medical  Journal,  December,  1895w 


STERILIZED  MILK.  163 

will  have  been  noticed  by  most  medical  practitioners  that  there  is  a  very 
distinctly  appreciable  lowered  vitality  in  infants  which  are  fed  on  boiled 

milk.  The  process  of  absorption  is  more  delayed  and  the  quantity  of  miJTc 
required  is  distinctly  larger  for  the  same  amount  of  growth  and  nourish- 
ment of  the  child  than  is  the  case  when  fresh  milk  is  used. 

Vaughan  does  not  believe  that  milk  is  benefited  by  either  sterilization 
or  pasteurization,  but  such  procedure  is  necessary  when  marlcet  milk  is  used, 
because  the  latter  is  seldom  or  never  obtained  under  aseptic  precautions. 

Some  people  have  an  idea  that  it  matters  not  how  filthy  a  cow's  milfc 
is,  or  how  many  germs  it  may  contain,  if  it  he  pasteurized  or  sterilized  it 
then  becomes  a  fit  food  for  children.  This  is  not  true,  because,  in  the  first 
place,  even  prolonged  foiling  does  not  kill  the  spores  of  all  bacteria;  and, 
in  the  second  place,  the  chemical  poisons  produced  by  certain  germs  are  not 
altered  by  the  temperature  of  boiling  milk. 

After  milk  has  been  either  sterilized  or  pasteurized  it  should  be  kept 
at  a  low  temperature  before  being  fed  to  the  child.  This  should  be  regarded 
as  a  necessary  procedure  in  the  preparation  of  infant  food.  The  fact  that 
milk  in  which  the  colon  germ  has  already  grown  abundantly  cannot,  by 
any  process  of  sterilization  or  pasteurization,  be  rendered  fit  food  for  chil- 
dren should  be  emphasized.  The  toxin  of  the  colon  bacillus  may  he  heated 
to  180°  G.  (S56°  F.)  for  half  an  hour  without  having  its  poisonous  prop- 
erties diminished.  If  clean  milk  he  obtained  and  heated  at  lJfO°  F.  to  150° 
F.  and  then  for  ten  to  fifteen  minutes  kept  at  a  low  temperature  until  fed 
to  the  child,  it  furnishes  the  best  food  which  it  is  possible  for  us  to  obtain 
under  ordinary  circumstances. 

Sterilization  of  Milk  at  212°  F.  for  Thirty  Minutes  (Soxhlet  Method). 
— Bottle-cleaning:  Always  cleanse  the  bottles  thoroughly  before  using 
them  if  they  are  new  bottles.  It  is  a  good  plan  to  give  them  one  good 
v/ashing  by  adding  a  pinch  of  bicarbonate  of  soda  to  each  bottle,  boiling 
for  at  least  five  minutes  in  this  soda  water,  and  then  boiling  for  at  least  a 
quarter  of  an  hour  in  ordinary  water.  The  bottles  are  then  turned  upside 
down  to  allow  the  water  to  drain  off,  I  then  insert  a  large  stopper  of  non- 
alisorbent  cotton  (sterilized  non-absorbent  cotton  from  a  dmg  store  is 
better  than  the  white  absorl)ent  cotton).  The  nock  of  tlH>  hottlo  is  stopporod 
at  least  throe-quarters  of  an  inch. 

Place  the  l)ottIes  ])reviously  filled  with  milk  or  the  feeding  mixture 
in  the  rack,  and  set  the  rack  in  the  sterilizing  chainher,  and  cover  tightly 
with  the  lid  and  hood. 

Fill  the  reservoir  ())an)  two-thirds  full  of  water  and  ])]aco  the  appa- 
ratus over  a  moderate  fire  for  one  hour.  If  the  milk  is  just  from  the  cow 
■forty  or  fifty  minutes  are  sufficient  (twenty  minutes  for  heating  and  twenty 
or  thirtv  minutes  for  sterilization). 


164 


INFANT  FEEDING. 


The  storilizcr  may  be  nsed  on  a  gas  stove  (turned  low),  kerosene  stove, 
or  upon  an  ordinar}^  cooking  stove;  if  over  tlio  last  named,  the  griddle 
shonld  not  bo  removed.  You  can  toll  by  a  biiliMiiiii-  sound  that  the  steril- 
izer is  working  all  right.  If  the  Avatcr  is  not  bubbling  with  regulariiy  in- 
side, you  need  more  heat.  It  must  not  ho  put  on  the  fire  without  water  in 
the  reservoir  and  the  water  should  never  be  allowed  to  get  lower  than  one 
inch  from  the  bottom.  With  proper  attention  as  to  the  quantity  of  water 
iu  the  reservoir  no  further  care  need  be  given  to  the  apparatus  or  to  the 
contents  of  the  chamber,  for  the  prescribed  time. 

It  is  not  necessary  to  place  the  bottles  on  ice  after  removing  them  from 
the  sterilizer,  but  all  bottles  should  be  placed  in  a  refrigerator  until  taken 
out  for  feeding,  leaving  in  the  cotton  plugs  until  it  is  feeding  time.    The 


Fig.  51. — Arnold  Steam  Steiilizcr. 

directions  sent  out  with  some  sterilizers,  that  milk  will  keep  for  days  ini- 
})lics  that  infants'  milk  may  be  prepared  for  several  days  at  once.  To  this 
I  decidedly  object.  A  great  many  authors  have  pointed  out  cases  of  Barlow's 
disease  due  to  milk  which  had  been  sterilized  and  not  used  for  a  long  time. 
Before  feeding  tlie  bottle  is  to  be  thoroughly  warmed  by  putting  it  into  a 
small  measure  or  bottle-holder,  and  heating  it  Math  alcohol  or  gas  to  about 
the  body  temperature  of  98°  or  100°  P.  Immediately  before  using  shake 
the  bottle,  so  as  to  mix  the  cream  and  the  milk,  which  invariably  separates 
in  a  refrigerator;    remove  the  cotton  and  draw  on  the  nipple. 


Pasteur  rzATioN. 

Heating  milk  to  75°  C,  as  is  done  by  jnany  of  the  methods,  does  not 
sterilize,  for  the  spores  of  the  bacillus  sul)tilis  can  withstand  this  temperature 
for  several  days.  The  spores  Avill  resist  the  tem])erature  of  100°  C.  (212° 
F.)   for  six  hours.     Upon  heating  to  110°  to  120°   C.   (230°  to  248°  F.) 


PASTEURIZED  MILK. 


165 


the  milk  will  be  thoroughly  sterilized,  but  such  heating  causes  a  browning 
of  the  milk,  and  the  cream-cells  are  apt  to  be  broken  and  the  fat  or  butter 
will  rise  to  the  surface. 

Pasteurization  with  a  temperature  between  60°  and  80°  C.  (140°  to 
176°  F.)  destroys  tubercle  bacilli  and,  according  to  Van  Geuns,  destroys 
also  the  typhoid  bacillus,  the  cholera  bacillus,  and  the  pneumococcus  of 
Fried  lander,  and  also  most  of  the  ordinary  milk  germs,  and  does  not  injure 
the  milk. 

C.  H.  Stewart  gives  the  following  interesting  result  of  the  heating  of 
milk  at  various  temperatures,  and  its  result  on  the  albumin:— 


Table  No.  32 

Time  of  Heating. 

Soluble  Albumin 
in  Fresh  Milk. 

Soluble  Albumin 
in  Heated  Milk. 

10  minutes  at  60°  C.  (140°  F.) 

30  minutes  at  60°  C.   (140°  F.) 

10  minutes  at  65°  C.  (149°  F.) 

30  minutes  at  65°  C.   (149°  F.)       

Per  Cent 
0.423 
0.435 
0.395 
0.395 
0.422 
0.421 
0.380 
0.380 
0.375 
0.375 

Per  Cent 
0.418 
0.427 
0.362 
0.333 

10  minutes  at  70°  C.   (158°  F.)       

30  minutes  at  70°  C.   (158°  F.) 

10  minutes  at  75°  C.   (167°  F.) 

30  minutes  at  75°  C.   ( 167°  F. ) 

10  minutes  at  80°  C.   ( 176°  F. )       

30  minutes  at  80°  C.  (176°  F.) 

0.269 
0.253 
0.070 
0.050 
none 
none 

We  can  see  that  heating  milk  at  140°  F.  for  ten  minutes  or  for  thirty 
minutes  still  leaves  about  the  same  proportion  of  soluble  albumin  as  we 
find  it  in  fresh  milk.  When  milk  is  heated  only  ten  minutes  at  176°  F. 
no  soluble  albumin  remains,  while  in  fresh  milk  about  0.375  is  found. 

An  interesting  bacteriological  report  was  made  on  pasteurized  milk 
by  a  committee  representing  a  medical  society  of  Washington,^  of  which 
the  following  synopsis  is  well  worth  noting: — 

"The  number  of  bacteria  per  cubic  centimeter  in  pasteurized  milk  has 
been  found  as  a  rule  to  be  less  than  200.  In  some  cases  no  bacteria  could 
be  detected.  In  four  instances  the  number  of  bacteria  per  cubic  centimeter 
increased  to  over  5000.  A  comparison  with  the  number  of  bacteria  in  the 
sanitary  milk  on  these  same  dates  showed  a  very  much  larger  number  of 
germs  than  should  have  been  present  if  proper  precautions  had  been  used. 
In  113  samples  of  sanitary  milk  examined,  the  number  of  colonies  per 
cubic  centimeter  has  in  the  majority  of  cases  varied  from  200  to  5000. 
Three  samples  showed  over  50,000  colonies  per  cubic  centimeter;  3  others 
over  20,000  and  less  than  50,000  colonies  per  cubic  centimeter;  1  over 
15,000  and  less  than  20,000  per  cubic  centimeter;  2  others  over  10,000 
and  less  than  15,000;  2  others  over  5000  and  less  than  10,000. 

*  Published  in  the  National  Medical  Review,  Washington,  D.  C,  April,  1899. 


16(j  I^^FANT  FKEDllsG. 

"When  we  consider,  however,  that  in  the  milk  supply  of  our  large 
cities  the  number  of  bacteria  per  cubic  centimeter  has  been  found  to  vary 
from  30,0U()  to  85,000,000,  and  has  often  been  found  as  high  as  the  number 
of  bacteria  in  the  sewage  of  several  towns,  namely,  between  1,000,000  and 
4,000,000  ])er  cubic  centimeter,  the  value  of  the  number  of  bacteria  per 
cubic  centimeter  of  milk,  as  indicating  the  care  which  has  been  used  in 
collecting  and  handling  the  milk,  is  at  once  apparent.  One  of  the  German 
authorities  on  the  subject  of  sanitary  milk  (Bitter)  claims  that  the  maxi- 
mum limit  for  milk  that  is  fit  for  food  is  50,000  gernis  per  cubic  centi- 
meter. On  tliis  basis,  the  milk  from  only  thirteen  out  of  thirty-two 
dairies,  which  has  been  examined  in  Washington,  would  be  fit  for  food." 

There  is  a  slight  taste  or  flavor  which  is  noticeable  when  milk  is 
heated  to  158°  F.  for  fifteen  minutes.  For  practical  purposes,  however, 
milk  healed  lo  lJfO°  F.  serves  very  well  and  has  no  taste  at  all.  Pasteurization 
of  milk  has  been  received  by  the  profession  with  the  same  enthusiasm  as 
was  sterilized  milk  when  it  was  first  announced.  The  mistakes  that  have 
been  made  by  forcing  infants  to  swallow  milk  sterilized  at  a  temperature 
of  213°  F.  for  thirty  minutes  are  evident  in  so  far  as  such  children  can 
show  a  devitalized  condition  into  womanhood  and  manhood.  Constipation 
and  rickets  are  recognized  as  associate  factors  during  sterilized  milk  feed- 
ing. The  profession  at  large  is  rapidly  departing  from  this  improper  and 
dangerous  method  of  treating  raw  milk. 

What  has  been  said  of  sterilized  milk  applies  in  a  lesser  degree  to 
pasteurized  milk.  I  have  frequently  found  cases  of  infants  fed  on 
pasteurized  milk  that  showed  the  same  symptoms,  though  in  a  milder 
degree,  than  what  we  know  to  be  true  of  sterilized  milk  feeding. 

When  my  advice  is  sought  regarding  the  utility  of  pasteurizing  mill-, 
I  always  say:  You  should  pasteurize  your  milk  at  a  temperatufe  of  1J^0°  to 
150°  F.,  for  ten  minutes,  if  you  do  not  know  the  source  of  your  milk  supply. 
In  New  York  certified  milk  or  guaranteed  milk  is  procured,  and  it  is  un- 
necessary to  change  the  chemical  character  of  the  milk  by  prolonged  heating. 
With  certified  milk  it  is  simply  necessary  to  use  sterile  utensils  and  warm 
the  food  to  a  little  higher  than  feeding  temperature. 

The   Caloric   Method  of   Infant  Feeding.^ 
A  calorie  is  the  amount  of  heat  necessary  to  raise  the  temperature  of 
one  kilo  of  water  one  degree    (Celsius),  in  other  words  it  is  the  deter- 
mination of  the  heat-energy  expressed  by  a  given  number  of  calories  as 
applied  to  infant  feeding. 

1  gram  or  cc.  of  fat  equals 8.4  calorics  or  9  calories 

1   gram  or  c.c.  of  sugar  equals 4.1  calories  or  4  calories 

1  gram  or  c.c.  of  proteid  equals 4.1  calories  or  4  calories 

1  Archives  of  Podiatrics,  Feb.,   1007;   also  Maynard  Ladd,  March,   1908. 


THE  CALORIC  METHOD.  167 

Caloric  value  per  liter  of  the  various  foods: — 

Breast-milk 050  calories 

Full  milk    G50 

One-half  milk  without  sugar 300  " 

One-half  milk  with  5  per  cent,  sugar 500  " 

Two-thirds  milk  with  5  per  cent,  sugar 000  " 

Buttermilk  without  sugar   300  " 

Buttermilk  with  5  per  cent,  sugar    500  " 

Malt  soup  (formula  as  given) TOO  " 

To  Make  Mull  ^viuj. 

Cold  water    00(i  parts 

Full  milk  4  per  cent 333 

White  Hour 50 

Malt  extract    ( Loeflund's  i     100 

Mix  flour  and  water  and  bring  to  boil.  Then  add  malt  extract  stirring  con- 
stantly, and  bring  to  boil.  Lastly  add  the  milk,  stirring  constantly.  Bring  to  boil 
three  times.     Cool  it  off  quickly  by  standing  it  in  cold  water. 

The  requirement  for  the  first  three  months  is  100  calories  for  each 
kilo  of  weight,  for  the  second  quarter  year,  about  90  calories. 

Later  on  the  requirement  is  80  calories,  and  some  infants  at  end  of 
six  months  do  not  require  more  than  70  calories  per  kilo.  Emaciated  and 
})remature  infants  require  120  or  more  calories  for  each  kilo. 

The  following  case  will  illustrate  the  method  of  caloric  feeding  as 
used  hy  me  in  the  Babies'  Wards  of  the  Sydenham  Hospital : — 

.Baby  B.,  was  admitted  to  the  hospital  October  17,  1909.    He  was  a  premature 
infant  weighing  1.90  kilo.     He  was  fed  on  a  formula  containing:  — 

Milk    1  ounce 

Sterile  water.  4  ounces,  with  5  per  cent,  lactose  solution. 

The  following  table  shows  the  weight  and  amount  of  calories  given. 

Table  No.  33. 
Date  Weight 

Oct.  19  1.90  kilos 

Oct.  20  1.94  kilos 

Oct.  21 2.05  kilos 

Oct.  22  1.95   kilos 

Oct.  23  2.10  kilos 

Oct.  24  2.15  kilos 

Oct.  25  2.15  kilos 

Oct.  26  2.18  kilos 

Oct.  27  2.22  kilos 

Oct.  28 2.22  kilos 

Oct.  29  2.25  kilos 

Oct.  30  2.27  kilos 


Amount  of 
Formulae 
19.      oz. 

Calories 
190 

21. 

oz. 

210 

20.5 

oz. 

205 

19.5 

oz. 

195 

21. 

oz. 

215 

19.5 

oz. 

195 

IS. 

oz. 

180 

19. 

oz. 

190 

22. 

oz. 

220 

25. 

oz. 

250 

24. 

oz. 

240 

24. 

oz. 

240 

1()S  IM-'AXT  FKKDINC. 

Date  Weight  Amount  of  Calories 

Formulae 

Oct.  31     •2.;5(»   kilos  24.  oz.  240 

Nov.  1      2.2S   kilos  27.  oz.  270 

-Nov.  2      2.;i()  kilos  ;!().  oz.  300 

-Nov.  3      2.30  kilos  ;;().  oz.  3(10 

-Nov.  4      2.30  kilos  ;!3.  oz.  330 

Xov.  .")      2.33  kilos  3(i.  oz.  3t)0 

Nov.  (i      2.3()  kilos  ;'.(1.  oz.  3(i0 

Xov.  7       2.3()   kilo.s  27.  oy..  270 

-Nov.  S       2.3(1   kilos  30.  oz.  3ti0 

Xov.  !t       2.40   kilos  33.  oz.  330 

Xov.  10    2.40  kilos  3(i.  oz.  300 

Xov.  11    2.43  kilos  30.  oz.  :i(iO 

Nov.  12    2.40  kilos  .!(i.  oz.  3G0 

On  Xo\L'iiil)er  13th  tlu'  foniiula  was  changed  to:  — 

^lilk   1  '/-  ouiift'.s. 

Sterile  water  3  '/..  ounces,  with   ">   per  cent,   lactose  solution. 

-Nov.  13  2.43  kilos  33.  oz.  3,St) 

Xov.  14  2.43  kilos  33.  oz.  3S() 

Xov.  1.5  2.53  kilos  3(i.  oz.  421 

-Nov.  10  2.00  kilos  30.  oz.  421 

Xov.  17  2.50  kilos  3().  oz.  421 

Xov.  IS  2.50  kilos  30.  oz.  421 

Xov.  1!)  2.50  kilos  30.  oz.  421 

Xov.  20  2.59  kilos  30.  oz.  421 

Xov.  21  2.59  kilos  30.  oz.  421 

Xov.  22  2.03  kilos  3().  oz.  421 

Nov.  23  2.03  kilos  36.  oz.  421 

From  a  study  of  the  aliovr  \\ci>;lit.  and  the  amount  oT  ralories  fcil 
to  this  infant,  we  can  follow  the  steady  gain  in  weigiit.  The  plan  ptirsued 
was  to  continue  the  same  numhci-  of  calories  as  long  as  the  infant  sliowed 
a  gain  in  weight.  For  instance:  on  Xovemher  lo,  the  weight  was  2J)a 
kilos,  and  4"^1  calories  wei'c  gi\'en.  Although  this  same  formula  was 
continued  for  one  week,  the  infant  steadily  gained  in  weight. 


Milk   Idiosynckasies. 

8omc  children  will  not  tolei-ate  milk;  physicians  freqncntly  report  an 
intolerance  of  milk  or  its  dilutions  in  children.  This  condition  has  long 
been  known  among  adults.  We  frequently  hear  adults  say  that  milk 
makes  them  bilious;  that  it  is  not  tolerated,  and  that  they  feel  uncomfort- 
able after  a  milk  diet.  Wliile  this  condition  is  of  much  rarer  occurrence 
in  children,  certain  cases  are  met  in  which  milk  is  not  tolerated.  It  has 
been  the  milk  itself  or  the  component  parts  of  the  same  that  has  disagreed 


-AllLK  IDIOSYXCRASIES. 


1(59 


in  certain  children  under  the  treatiiiciit  of  the  writer.  Breast-milk  and 
several  changes  of  wet-nnrses  gave  the  same  distressing  symptoms.  Cows' 
milk  was  not  tolerated  and  was  discontinued  after  various  dilutions. 

The  following  case  will  serve  to  illustrate  what  is  meant  Ijy  the  above 
condition : — 

C.\SE  I. — An  infant.  M.  L..  was  born  in  July.  1901.  Tlie  weiglit  at  birth  was 
about  six  pounds.  The  mother  had  no  milk,  so  a  wet-nurse  was  secured.  The  infant 
was  wet-nursed  for  the  next  tliree  months.  Tlie  cliild  gained  about  eiglit  ounees 
per  week  during  tlie  month  of  July,  but  in  August  and  September  it  did  not  thrive. 

Uislonj  of  Food  After  Weajiiiu/. — When  the  child  was  weaned,  in  October,  it 
was  given  condensed  milk,  one  drachm  to  t\\elve  drachms  of  .sterile  water,  to  wliicli 
one  draclim  of  lime-water  was  added.  The  child  vomited  and  liad  eructations,  al- 
though it  had  from  one  to  two  yellowish  stools  i)er  day.  When  this  child  was  weaned 
it  was  constipated  and  reipiircd  an  enema  of  ])laiu  water  to  relieve  the  bowel.  The 
stools  during  the  summer  mouths  contained  a  great  deal  of  mucus  which  was 
sliredded  and  yellowish-green  in  color.  Tlie  infant  was  colicky;  the  stools  liad  a  very 
sour  smell;  the  child  frequently  had  an  explosive  vomit.  The  condensed  milk  was 
continued  through  the  numtli  of  October,  and.  as  tlie  cliild  did  not  seem  to  thrive,  it 
Mas  given  Jusfs  Food.  This  the  child  refused,  so  Xestle's  Food  was  substituted  and 
seemed  to  agree.  V\'hen  milk  was  added  the  child  vomited  a  sour-smelling  liquid,  and 
later  on  refused  Xestle's  Food.  As  there  was  constant  anorexia,  the  child  was 
next  fed  with  Ridge's  Food.  As  this  was  not  very  well  borne,  a  trial  was  made  of 
Allenbury's  Food.  When  this  disagi'eed.  the  child  was  placed  on  Eskay's  Albumin- 
ized Food.  This  also  was  not  tolerated  and  the  child  was  given  some  strengthening 
meal.     This  was  not  born.'  any  better. 

K.c<nnin(ttion. — On  X'ovember  24,  the  child  weighed  about  nine  pounds.  It  had 
lost  eight  ounces  the  week  ])revious  to  its  parents  consulting  me.  This  loss  of  weight 
disturbed  the  family  and  caused  them  to  seek  a  change  of  diet.  The  examination  of 
the  child  showed  some  very  interesting  facts.  First,  the  general  appearance  of  the 
child  was  one  of  an  luidersized.  undeveloped,  nuirkedly  rachitic  baby;  there  were 
beaded  ribs;  tlu;  ends  of  the  long  bones,  ])articularly  the  radius,  ulna  and  feniur 
were  markedly  rachitic.  Subluxation  of  the  knee-joints  was  present.  The  head  of 
the  child  was  very  rachitic;  the  fontanel  was  very  widely  open:  in  fact,  the 
fontanel  was  three  times  the  size  of  that  of  a  normal  baby.  The  extremities  were 
extremely  cnld ;  the  circulation  was  \ery  jioor;  the  action  of  (he  heart  was  very 
fecbli-;  a  blowing  uuirmur  was  distinctl\-  heard  at  the  apex  and  eniild  also  be  heard 
in  the  \-essels  of  the  iicek.  It  was  a  distinct  luemie  muiiuur  and  attiibuted  to  the 
profound   ana'iuic   condition   which    existed. 

The  trained  nurse  in  charge  of  the  case  had  been  with  the  baby  since  birth  and 
had  stated  that  the  child  had  liad  a  series  of  spasms  which  were  not  only  regular, 
clonic  and  tonic  contractions,  but  they  occurred  once  every  twenty-four  hours  at  a 
certain  tinu^  of  the  day.  The  child  was  very  fretful,  very  nervous,  constantly 
irritable  and  had  had  very  restless  sjxdls  at  night  which  disturbed  its  sleep.  There 
was  a  slight  erupt  ion  aionnd  the  anus;  the  child  had  dillicnlty  in  taking  the  nipple 
as  well  as  nursing  ,\i   the  bieast. 

An  examination  of  the  throat  showed  congenital  adenoid  vegetations.  This  lat- 
ter condition  interfered  with  the  child's  proper  feeding;  it  jjrevented  the  child  from 
proi)erlv  taking  its  food  and  breathing  at  the  same  time.  It  would  take  the  nijiiilo 
or  the  breast  and  then  let  go,  in  order  to  breathe.     Spoon  feeding  was  resorted  to 


170  INFANT  FEEDING. 

wlicn  the  cliild  would  nut  take  food  fioin  its  Ixtttle.  Attention  was  directed  to  the 
rhino-pharynx.  By  gradual  cauterization  the  eliild's  condition  was  so  markedly 
improved  that  its  general  c-ondition,  with  the  appetite,  stools,  sleep  and  weight,  all 
assumed  normal  tendencies. 

Dietetic  Treatment. — The  child  was  given  the  following:  — 

IJ   Whey     2       ounces 

:Milk    2  V,  ounces 

Peptogciiii'   |><)\\(lcr Half  a   inciisure  of  the  metal  caj) 

Granulated  sugar   Half  a  teasjioon 

IMix  the  above  and  ])!'pl()iii/.:'  llic  milk  hy  a  slow  jiroress  for  about  ten  minutes 
and  A\hen  cooled  to  the  proper  feeding  temperature  feed  the  above  quantity  every 
three  hours. 

The  child  took  the  bottle  veiy  well;  in  fact,  took  four  ounces,  retained  the  food 
and  seemed  to  like  it.     The  following  are  the  nurse's  reports:  — 

"November  24,  10.30  P.M.,  took  four  ounces,  has  not  vomited,  seems  to  like 
food." 

"November  25,  4  A.M.,  took  four  and  one-half  ounces  of  food,  retained.  At 
7  A.M.  took  nearly  four  ounces,  retained.  At  11  a.m.  child  crying  and  abdomen 
distended,  cliild  appears  colicky." 

A  warm  enema  consisting  of  two  pints  of  chamomile  tea  was  ordered  so  that  tha 
colon  and  rectum  were  thoroughly  flushed.  The  child  was  instantly  relieved  after 
some  cheesy  curds  and  mucus,  plus  faeces,  were  washed  away.  These  fermentative 
conditions,  resulting  in  gaseous  eructations,  colicky,  distended,  tense  abdomen,  with 
crying  and  occasional  cheesy,  curdy  stools,  the  temperature  frequently  reaching  101 
to  103  in  the  rectum,  occasional  vomiting  and  disturbed  appetite  were  invariably 
noticed  when  milk,  peptonized  or  predigested  or  in  any  form,  was  given  to  this  child. 

It  was  therefore  apparent  to  me  that  this  baby  would  not  digest  milk  and  hence 
some  other  form  of  feeding  was  required.  On  December  17th  a  new  form  of  feeding 
Avas  commenced  which  is  knoMTi  as  a  modified  form  of  malt  soup.  A  similar  plan  of 
feeding  is  used  extensively  abroad,  at  the  foundling  asylums  which  I  visited;  notably 
at  the  New  Berlin  Foundling  Asylum,  which  is  under  the  supervision  of  Dr.  Finkel- 
stein.  This  food  is  known  as  Keller's  malt  soup.  Its  preparation  is  rather  difficult 
unless  performed  by  a  competent  chemist.  This  food  has  been  used  for  many  years 
in  the  nursling  pavilion  of  the  Kaiser  and  Kaiserin  Friedrich  Children's  Hospital, 
imder   the   direction   of  Professor   Baginsky. 

I  am  indebted  to  the  New  York  Walker-Gordon  Laboratory  for  great  care  in 
the  preparation  of  this  fcpod,  which  has  certainly  served  me  very  well.  The  following 
formula  was  used  in  the  beginning  and  was  changed,  as  can  be  seen  by  studying  the 
accompanying  table. 

KELLER'S    MALT    SOUP. 

Take  of  wheat  flour  2  ounces  and  add  to  it  11  ounces  of  milk.  Soak  the  flour 
thoroughly  and  rub  it  through  a  sieve  or  strainer. 

Put  into  a  second  dish  20  ounces  of  water,  to  which  add  3  ounces  of  malt 
extract;  dissolve  the  above  at  a  temjierature  of  about  120°  F.,  and  then  add  2V2 
drachms  of  11  per  cent,  potassium  bicarbonate  solution. 

Finally,  mix  all  of  the  above  ingredients  and  boil.  This  gives  a  food  contain- 
ing: albuminoids,  2.0  per  cent.;  fat,  1.2  per  cent.;  carbohydrates,  12.1  per  cent. 
There  are  in  this  mixture  0.9  per  cent,  of  vegetable  proteids. 


MILK  IDIOSYNCRASIES. 


171 


The  wheat  flour  is  necessary,  as  other 
wise  the  malt  soup  would  have  a  diarrhoea! 
tendency.  The  alkali  is  added  to  neutralize 
the  large  amount  of  acid  generated  in  sick 
children.  Biedert  emphasizes  the  importance 
of  giving  fat,  rather  than  reducing  its 
quantity,  in  poorly-nourished  children,  and 
cites  the  assimilability  of  his  cream  mixture 
or  of  breast-milk  in  under-fed  children  as 
proof  of  his  assertions.  The  author  has 
used  this  malt  soup  most  successfully  in 
the  treatment  of  athrepsia  (marasmus) 
cases  in  which  the  children  were  simply 
starved. 

On  studying  the  ingredients  one  can 
easily  see  that  the  malt  extract  and  the 
dextrinized  wheat  are  highly  nutritious 
agents.  We  know  that  dextrinized  wheat 
is  very  well  absorbed  by  some  of  the  young- 
est infants.  The  addition  of  the  potassium 
bicarbonate  served  to  render  the  food 
markedly  alkaline,  which  is  an  extremely 
important  thing.  AVhen  milk  was  added 
with  the  object  of  increasing  the  percentage 
of  fat  and  proteid,  we  deviated  from  the 
quantity  as  originally  recommended  by 
Keller.  Colic  and  gastroenteric  fermenta- 
tion was  invariably  encountered.  A  study 
of  the  weight  chart  is  extremely  interesting. 

Case  2.— The  child,  S.  N.,  born  of 
healthy  parents,  was  put  to  the  breast  on 
the  second  day  after  birth.  On  the  third 
day  after  birth  there  was  a  profuse  flow  of 
milk.  The  infant  appeared  quite  well  satis- 
fied after  nursing. 

The  child  was  nursed  every  two  hours ; 
was  changed  from  the  right  to  the  left 
breast  at  every  other  feeding.  Fifteen  to 
twenty  minutes  after  each  nursing  there 
were  symptoms  of  restlessness  and  constant 
crying.  The  legs  were  flexed  on  the  abdo- 
men; there  were  eructations  and  all  the 
evidences  of  colic.  The  child  cried  at  least 
one  hour,  until  it  fell  asleep  from  exhaus- 
tion. This  state  of  afTairs  continued  each 
day  for  at  least  two  weeks.  A  specimen 
of  breast-milk  was  examined  by  a  chemist 
and  found  to  be  perfectly  normal  in  its 
elements  and  in  their  relative  percentages. 

The  family  was  greatly  distressed  at 
its  continued  crying  and  apparently  colicky 


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172 


INFANT  FEEDING. 


condition,  but  was  surpiised,  in  spite  of  this  condition,  to  find  that  the  infant  gained 
between  four  and  six  ounces.  It  was  necessary  to  give  1  to  2-grain  doses  of  chloral 
hydrate  at  night  to  procure  sleep.  We  finally  decided  to  change  the  mother's  milk 
and  to  substitute  a  wet-nurse.  The  child  behaved  just  as  badly  with  the  wet-nurse, 
Iiad  the  same  crjang  spells  shortly  after  nursing,  which  continued  frequently  for 
oi;e  hour.  When  the  breast  was  discontinued  for  one  day  and  barlej'-water  or 
albumin-water  substituted,  the  child  would  appear  comfortable,  and  not  have  the 
pains  wliieh  we  noted  while  feeding  breast-milk. 

The  stool  was  filled  with  large  cheesy,  curdy  masses.  To  aid  the  assimilation 
of  the  milk,  small  doses  of  pancreatin  and  bicarbonate  of  soda  were  given;  with  the 
idea  of  partially  peptonizing  the  milk,  essence  of  caroid,  a  half  teaspoonful  before 
each  feeding,  was  also  prescribed.  In  addition  thereto  small  quantities  of  essence  of 
pepsin  and  hydrochloric  acid  were  given  after  each  feeding,  to  aid  the  digestion  of 
tliis  food.  Neither  of  these  medications  relieved  the  condition  and  I  finally  decided 
tliat  the  breast-milk  was  not  adapted  for  this  child.  We  next  resorted  to  very 
diluted  cows'  milk,  using  one  part  milk  with  three  parts  oatmeal  water.  We  grad- 
ually increased  the  strength  until  one-half  milk  and  one-half  oatmeal  water  was 
given. 

Table  No.  34.— Case  S. 


No.  of 
Tubes. 

Dex. 

Wh. 

Distilled 

Barley 

Malt 

Wfo  Pot. 

Date. 

Oz. 

Wheat 
Oz. 

Milk. 
Oz. 

Water 
Oz. 

Jelly. 
Oz. 

Extract. 
Oz. 

Bicarb. 
SoL  Dr'm. 

May  28,  1903    . 

7 

6 

U 

14 

28 

3 

3^ 

May  29,  1902    . 

7 

6 

^ 

m 

m 

2 

U 

Mav  30,   1902   . 

7 

7.V 

\h 

35 

14 

3J 

2 

^ 

May  31,  1902   . 

10 

7.^ 

2\ 

52 

21 

5i 

3 

•H 

June   2,  1902    . 

7 

^ 

u 

35 

14 

Zli 

2 

H 

June   5,  1902    . 

7 

7^ 

li 

35 

14 

4 

■   •    • 

3i 

:Milk,  however,  in  any  form,  whether  diluted  or  pure,  was  poorly  borne.  When 
cereal  decoctions  were  substituted,  they  were  invariably  better  tolerated.  The  same 
was  true  when  soups  and  broths  were  given.  The  latter  were  always  well  borne, 
and  the  moment  milk  was  added,  no  matter  in  what  form,  trouble  was  immediately 
encountered. 

An  interesting  point  is  the  fact  that  all  infanta  having  the  milk  idiosyncrasy 
had  elevated  temperatures  ranging  fiom  101  to  102  continuously. 


CHAPTER  IV. 
LABORATORY  MODIFICATION  OF  MILK.  > 

It  is  now  several  years  since  a  Walker-Gordon  milk-laboratory  was 
established  in  New  York.  Their  method  of  feeding  infants  is  based  on 
mixing  the  ingredients  in  such  combination  that,  when  combined,  they 
should  resemble  certain  chemical  formula  of  breast-milk  at  various  ages. 
Blanks  are  given  the  physician,  which  are  filled  out  according  to  the  indi- 
vidual requirement.  The  age  and  weight  are  noted.  Fat,  sugar,  proteid, 
and  water  are  prescribed  in  percentages.  We  are  therefore  able  to  state  that 
the  food  ordered  contains  a  definite  percentage  of  fat,  sugar,  caseinogen,  and 
lactalbumin.  The  same  is  also  true  regarding  the  heating  of  food.  We  can 
prescribe  the  food  sterilized,  pasteurized,  or  raw.  A  great  many  changes 
can  be  made.  We  can  increase  or  decrease  the  fat;  the  same  is  true  of  sugar 
and  proteids. 

My  advice  to  those  using  modified  milk  is  to  begin  with  low  proteids. 
An  infant  at  birth,  if  deprived  of  breast-milk,  should  never  receive  more 
than  0.50  per  cent,  of  proteids,  in  the  beginning  of  laboratory  feeding. 
Some  infants  do  very  well  on  0.25  per  cent,  of  proteids  soon  after  birth. 
It  is  a  simple  matter  to  note  the  infant's  condition,  its  stools,  its  sleep,  and 
its  weight. 

If  the  above-named  conditions  are  satisfactory,  then  we  can  increase 
the  proteids,  the  fat,  and  the  sugar.  Note  conditions  every  day,  and  have 
the  mother  or  nurse  in  charge  of  the  infant  report  the  slightest  disturbance. 
Vomiting,  if  present,  its  frequency  and  character,  should  be  carefully  noted. 
So  also  should  colicky  symptoms,  eructations,  flatulence,  and  greenish, 
curded  stools. 

Constant  crying,  disturbed  sleep,  and  restlessness  are  all  factors  that 
need  correction  and  supervision. 

The  quantity  of  food  prescribed  depends  upon  the  requirements  of  each 
child.  Some  children  can  take  3  ounces  at  one  feeding  while  others  appear 
satisfied  after  taking  2  ounces  of  food. 

Examples. — For  a  child  at  birth: — 


Fat 2.00 

Sugar 5.00 

Proteids    0.50 

Lime-water 5.00 


y  Formula  I 


*  Reprinted  from  "Infant  Feeding  in  Health  and  Disease."     Louis  Fischer,  M.D. 
Third  EdiUon.     F.  A.  Davis  Co.,  1903. 

(173) 


174 


INFANT  FEEDING. 


Or:- 

Fat 2.00 

Sugar 5.00 

Proteids    0.75 

Lime-water 5.00 


>■  Formula  lo 


^lilk,  raw,  pasteurized,  or  sterilized. 

Quantity  of  food  to  be  given,  2  ounces  every  two  hours. 

My  preference  for  food  prescribed  at  a  laboratory  where  germ-free 
milk  is  obtainable  is  to  prescribe  it  raw.  When  constipation  is  encountered 
the  raw  milk  will  modify  such  conditions. 

If  diarrhoea  or  looseness  exist,  then  my  preference  is  to  use  heated 
milk:   sterilized  from  ten  to  twenty  minutes. 

If  the  infant  thrives,  the  ingredients  can  be  increased;  also  the  quan- 
tity at  each  feeding: — 

Fat 2.50    ^ 

Sugar COO 

Proteids    100 

Lime-water 5.00 

Later,  if  conditions  warrant  it: — 


Formula  II 


Fat 3.00 

Sugar COO 

Proteids    1-50 

Lime-water 5.00 


Formula  III 


In  this  manner  we  can  gradually  ircvease  the  percentage  of  ingredients 
until  whole  milk  is  ordered. 

When  abnormal  conditions  prevail — such  as  loose  bowels — then  barley 
water  can  be  substituted  for  the  sterile  water. 

Case  T. — Tlie  following  formula  was  recently  prescril)ed  at  the  labora- 
tory for  a  child.  1  year  old.  with  very  loose  ))owels: — 

Whole  milk 15        ounces 

Kice-water 14        ounces 

Dextrinized  wheat 1        ounce 

Dry  cane-sugar  1  V»  ounces 

Cornstarch   2       teaspoonfuls 

To  be  thoroughly  mixed,  sttMilized  20  minutes,  and  divided  into  five  feedings, 
each  bottle  containing  6  ounces. 

Note. — Successful  laboratory  feeding  will  only  be  accomplished  when 
the  physician  is  willing  to  supervise  the  products  of  metabolism  and  in- 
crease or  decrease  the  ingredients  demanded  by  individual  symptoms.  For 
example:  hard,  dry  stools,  more  fat;  a  very  anemic  condition,  more  pro- 
teids and  fat;  a  restless  hungry  child  immediately  after  feeding  demands 
a  larger  quantity  of  all  ingredients. 


LABORATORY  MODIFICATION.  175 

When  the  bowels  acted  better,  and  had  a  more  solid  consistency,  I  added 
nialt  extract,  V2  teaspoonful  to  each  bottle.  When  imjjrovemeut  was  noted 
the  above  formula  was  chnugcd  to: — 

Wliole  milk 28        oulices 

Barley-water 20        ounces 

Cornstarch    1        ounce 

Diy  sugar G        drachms 

Dextrinized  wlieat   2  '/z  ounces 

Sterilize,  divide  into  eight  bottles  of  6  ounces  each. 

The  following  case  ilhistrates  Successful  Modified  Milk  Feeding 
With  ]\Iilk  Prepared  at  Walker-Gordon  Laboratory. 

Case  IT. — Baby  A.,  four  months  old,  was  seen  by  me  September  19,  1901,  with 
the  following  history:  It  was  the  first  baby,  forceps  delivery,  podalic  presentation; 
weight  at  birth,  about  6  pounds.  Family  history  excellent.  Nursed  at  mother's 
breast  about  four  weeks,  but,  OAving  to  a  scanty  flow  of  milk,  she  required  addi- 
tional hand-feeding.  The  baby  received  milk  and  barley  water,  sterilized  or  boiled. 
A  bottle  was  given  after  each  nursing  (so-called  mixed  feeding). 

Result:  Constipation:  relief  given  by  soap-suds  enema.  This  condition  lasted 
about  six  weeks.  The  child  had  colic  of  a  very  severe  foim  and  also  tenesmus:  i.e., 
constant  straining. 

Cliild  was  weaned  of  the  mothei-'s  breast;    food  ordered  was:— 

Milk 8  ounces 

Barley-water   IG  ounces 

Milk-sugar  3  teaspoonfuls 

Lime-water 2  teaspoonfuls 

Salt   10  grains   (pinch) 

Sterilize  thirty  minutes,  divide  into  eight  feedings,  and  feed  every  two  liours. 

When  about  two  months  old,  child  had  greenish,  spinach-like,  veiy  slimy  stools, 
also  containing  ichite  cm'ds.  The  infant  appeared  hungry  or  thirsty  all  the  time, 
was  restless,  had  insomnia,  and  suflTered  with  colic.  There  was  no  vomiting.  A 
pliysician  ordered  the  milk  discontinued  and  barley-water  given  instead.  The  child 
hecame  extremely  emaciated;  hence  was  removed  to  the  seashore.  At  the  seashore 
Hr.  J.  ordered:  — 

Milk  1  ounce 

Boiled  water 3  ounces 

Milk-sugar  and  salt. 

riiis  food  was  quite  well  tolerate<l.  When  oatmeal-water  was  given  instead  of 
barley-water,  to  ofTset  the  constipating  efTect,  a  miliary  eruption  appeared. 

During  the  second  week  of  September  the  cliild  still  had  diarrhoea.  Stools  still 
greenish,  containing  mucus  and  shreds.  The  rectum  prolapsed  from  constant 
tenesmus.     Cereal  milk  was  tried,  but  with  no  success. 

The  above  is  the  clinical  history  given  to  me  by  the  mother  of  the  infant. 


176  INFANT  FEEDING. 

Present  condition:  A  very  frail-looking  infant,  rather  emaciated.  Poor  circu- 
lation, cold  extremities,  pallor  of  skin,  anus  slightly  excoriated,  and  noevus  on  right 
side  of  thorax. 

Temperature  normal  in  rectum,  98  Vs  "  F.;  pulse,  120;  respiration,  28.  Throat 
normal,  tongue  moist  and  has-  grayish-white,  fur-like  coating.  Heart-sounds  feeble; 
slight  bronchitis,  diiliisc  sonorous  and  sibilant  rales  heard  on  both  sides  of  the  chest. 
Stomach  veiy  markedly  distended.  Abdomen  tj'mpanitic  on  percussion.  Colon  dis- 
tended.    Liver  enlarged.     Spleen  not  palpable. 

Diagnosis:  Chronic  dyspepsia,  atrophy  due  to  mal  assimilation  of  food,  and 
rickets. 

Prognosis:     Fair. 

Table  No.  3.'). 

Weight. 

September  19 8  lb.  15  oz.  (including  shirt  and  belly-band) 

September  25 9  lb.  12  oz.  "  "         "  " 

Gained 13  oz. 

October  2 10  1b.     2  oz. 

Gained 6  oz. 

October  ». 10  1b.     9  oz.  "  "         " 

Gained 7  oz. 

October  IG 111b.     2  oz. 

Gained 9  oz. 

October  23 11  lb.  U  oz. 

Gained 12  oz. 

October  30 12  1b.     G  oz. 

Gained 8  oz. 

November  30 15  1b.     7  oz.  "  "        "  " 

With  clothes. 

A  study  of  the  weight-chart  will  prove  very  interesting. 

The  dyspeptic  and  rachitic  baby  with  cold  exticinities  is  to  day  a  beautiful 
child,  well  developed,  and  was  not  seen  by  the  author  for  several  months — until  it 
was  necessary  to  vaccinate. 

Ordered:     Syr.  rhei  arom.,  3j  every  four  hours,  to  cleanse  gastrointestinal  tract. 

Also: — 

U  Strychnine  sulphate   0.002 

Sacchar.  alb 0.06 

Decoction  of  cinchona  (tlava) GO.O 

M.      Teaspoonful  after  feeding  three  times  per  day. 

The  above  as  a  cardiac  and  vascular  stimulant. 

September  20th:     Food  ordered  at  Walker-Gordon  laboratory: — 

Fat 2.50 

Sugar C.OO 

Proteids 1-50 

Lime-water    Vie 

Seven  feedings  of  6  ounces  each.  Use  raw  milk.  Feed  every  two  and  one-half 
houib. 


LABORATORY  MODIFICATION.  177 

The  followng  day  the  child  slept  from  8  p.m.  till  4  a.m. — eight  hours  con- 
tinuously. Had  three  pasty  stools.  Infant  appeared  satisfied  after  bottle.  It 
was  then  ordered  (September  22d) : — 

Fat 3.0 

Sugar 6.0 

Proteids 2.0 

Is'o  alkalinity. 
Raw  milk.      Seven  feedings,  G  ounces  in  each. 
Feed  every  two  and  three-fourths  hours. 

Cliild  seemed  much  better  satisfied  after  feeding;  vomited  once;  had  two  stools, 
both  of  yellowish  color,  and  of  good  consistency.  One  stool  at  5  a.m.  and  one  at 
5  P.M. 

ISeptember  2Stli: — 

Fat 3.50 

Sugar G.OO 

Proteids 2.00 

Pasteurize  the  food.     Si.K  feedings  of  G  ounces  each.      Feed  every  three  hours. 

When  bowels  acted  too  frequently  I  pasteurized  the  food;    not  otherwise. 

October  6th,  ordered:  Bran  and  sea-salt  baths  every  second  night;  temperatuic 
of  bath  95°  F. ;  followed  by  brisk  rubbing  to  stimulate  the  circulation.  The  digestion 
of  the  infant  being  excellent,  stools  regular,  the  percentage  of  ingredients  was  in- 
creased:— 

Fat 4.00 

Sugar 6.00 

Proteids 2.50 

Use  barley-jelly  instead  of  water;    alkalinity,  5  per  cent.     Heat  to  167°  F. 

Six  feedings,  of  6  ounces  each. 

Feed  evei-y  three  and  one-half  hours. 

Child  is  excellent,  gaining  in  weight;  sleeps  well;  stools  normal;  has  no  colic. 
Discontinued  laboratory  feeding. 

Home  modification: — 

Pure  raw  cows'  milk 30  ounces 

Barley-water  18  ounces 

Peptogenie  powder 3  teaspoonfuls 

Divide  into  six  bottles;    warm  each  bottle  before  feeding. 
Feed  every  three  and  one-half  hours. 

Add  the  larley-water  to  the  raw  milk  and  divide  into  six  equal  bottles,  then 
place  in  refrigerator  until  feeding-time.  At  feeding-time  empty  a  bottle  into  a  clean 
saucepan,  add  the  peptogenie,  and  wann  to  the  temperature  of  100°  F.  for  ten 
minutes;    then  boil  quickly  for  one  minute  and  cool  to  feeding  temperature. 

For  the  relief  of  constipation: — 

Infus.  senna  comp 2  ounces 

Saccharin 1  grain 

M.    Tcaspoonful  eveiT'  three  hours  until  bowels  move. 

13 


178  INFANT  FEEDING. 

After  a  few  days  abstracted  one  ounce  of  barley-water  and  added  one  ounce  of 
pure  milk,  until  after  a  few  weeks  the  cliild  received  whole  milk,  sweetened  with  one 
teaspoonful  of  granulated  sugar;    8  ounces  every  four  hours. 

Also  ordered  six  ounces  of  chicken-soup;  steak-juice,  gradually  thickened  with 
cereals;    some  egg-crackers,  zwieback,  and  bread-crumbs  in  soup. 

Later: — 

JMiik  (raw)    8  ounces 

Cream  V*  ounce 

Granulated  sugar 1  teaspoonful 

'V\'ann  in  a  saucepan  and  feed  eveiy  four  hours. 

Illustrative  Case — Unsuccessful  Laboratory  Feeding. — N.  R.,  a  healthy 
female,  was  put,  soon  after  birth,  on  modified  milk. 

October  14th:  Fat,  2.0;  milk-sugar,  5.0;  albuminoids,  0.75;  lime-water,  Vn- 
Eight  feedings;    2  ounces  in  each. 

October  17th:  Constipation.  Fat,  2.5;  milk-sugar,  CO;  albumin,  1.0;  lime- 
water,  Vw     Nine  feedings,  2Vs  ounces  in  each. 

October  27th:  Fat,  3.0;  milk-sugar,  6.0;  albuminoids,  1.0;  lime-water,  Vi*; 
barley-jelly,  Vw     Ten  feedings;    3  ounces  in  each. 

November  5th:  Fat,  3.5;  milk-sugar,  6.0;  albuminoids,  1.0;  lime-water,  Vw » 
barley-jelly,  Vw     Ten  feedings;    3  ounces  in  each. 

November  17th:  Fat,  4.0;  milk-sugar,  6.0;  albuminoids,  1.5;  lime-water,  '/»> 
no  barley.     Ten  feedings;    3  ounces  in  each. 

November  19th:  Curded  stools,  dyspeptic  diarrhoea.  Fat,  4.0;  milk-sugar,  6.5; 
albuminoids,  1.0;    lime-water,  Vao-     Ten  feedings;    3  ounces  in  each. 

The  child  did  not  increase  in  weight,  had  a  rectal  temperature  of  100°,  slightly 
furred  tongue,  vomited  curds,  had  greenish  stools  containing  undigested  particles  of 
fat  and  true  casein  and  large  masses  of  mucus.  The  diagnosis  of  dyspepsia  infantum 
was  made;  hand-feeding  was  stopped,  the  child's  alimentaiy  tract  was  cleaned  by 
giving  cascara  sagrada,  and  a  proper  wet-nurse  was  secured.  The  infant  at  tliis 
time  was  about  six  weeks  old.  The  child  nursed  very  well,  and  after  a  few  days  the 
stools  were  normal,  both  in  consistency  and  color.  The  infant  gained  steadily  from 
4  to  6  and  sometimes  8  ounces  per  week,  until  she  was  seven  months  old,  when  sud- 
denly the  weight  remained  stationary.  The  child  was  bright  and  cheerful,  but  I 
deemed  it  necessary  to  have  the  milk  of  the  wet-nurse  examined  by  a  competent 
chemist;  a  specimen  of  the  same  was  secured  in  the  usual  manner  described  by  me 
in  a  previous  section  on  "Specimen  of  Breast-milk  for  Chemical  Examination."  This 
specimen  was  examined  for  the  authc  r  by  John  S.  Adriance,  the  chemist  of  the 
Nursery  and  Child's  Hospital,  who  reported  the  following: — 

Fat 2.00  per  cent. 

Sugar 7.43  per  cent. 

Proteids    0.88  per  cent. 

Ash 0.16  per  cent. 

Total  solids 10.47  per  cent. 

Water 89.52  per  cent. 

Specific  gravity  at  70°  F 1031 

Reaction  alkaline. 

In  the  chemical  result  above  given  it  is  very  evident  that  a  deficiency  in  the 
proteids  exists;    hence  it  accounted,  not  only  for  the  stationary  weight,  but  for  the 


LABORATORY  MODIFICATION.  179 

late  dentition.     The  child  did  not  gain  an  ounce  in  one  month.     We  discharged  the 
wet-nurse.      The  following  food  was  ordered: — 

Milk 3  ounces 

Cream  2  teaspoonfula 

Oatmeal-jelly 3  ounces 

Lime-water   1  drachm 

Milk-sugar 1  teaspoonful 

Salt 1  pinch 

Pasteurize  the  above  and  feed  every  three  liours,  the  above  quantity  being  for 
one  feeding. 

After  tlie  infant  had  taken  this  food  for  six  days  it  was  cheerful,  had  had 
one  and  two  yellow  stools  daily,  and  gained  6  ounces  in  six  days. 

The  above  case  will  illustrate: — 

1.  That  the  child  was  decidedly  dyspeptic  while  taking  its  modified  milk  for 
about  six  weeks. 

2.  That  for  about  six  months  the  infant  thrived  very  well  on  the  milk  of  a  wet- 
nurse. 

3.  That  the  stationaiy  weight  of  the  infant  and  the  chemical  examination  of 
the  milk  of  the  wet-nurse  showed  deficient  proteids,  which  accounted  for  this  non- 
increase  in  weight  and  the  lateness  in  dentition. 

4.  That  a  proper  milk-mixture,  which  agreed  very  well,  suited  the  requirement 
of  this  infant,  and  emphasizes  the  fact  that  we  must  individualize  in  each  and  every 
case. 

It  is  impossible  to  make  an  emulsion  like  milk  from  its  component 
parts  by  a  synthetic  process.  Let  it  therefore  be  distinctly  understood  that, 
once  a  milk  emulsion  is  broken  up,  as  is  done  in  centrifuging  milk  and 
removing  the  cream,  mixing  the  whole  will  never  restore  the  uniformity 
of  the  emulsion  that  existed  prior  to  this  division. 

In  domestic  modification,  of  course,  the  same  care  must  be  taken  to 
secure  clean,  pure  milk  and  cream  from  healthy,  well-kept  cows.  This  is 
quite  possible  now  in  New  York,  and  is  becoming  easier  each  year,  as  more 
attention  is  being  given  to  infant-feeding  and  greater  demand  is  being  made 
for  a  pure  milk  supply.  Pasteurization  is  as  readily  done  in  the  nursery  as 
in  the  laboratory.  Accurate  measurement  of  quantities  and  cleanliness  of 
vessels  and  feeding-bottles  is  equally  possible  and,  in  my  experience,  quite 
as  certain  at  home  as  in  the  shop. 

Clinical  experience  has  demonstrated  the  fact  that  some  children  will 
thrive  on  condensed  milk  in  spite  of  faulty  hygiene,  while  others  will  not 
thrive  in  the  best  environment  with  the  best  form  of  feeding;  again,  some 
children  will  thrive  on  modified  milk,  others  will  not.  Some  cases  seen  by 
the  author  suffered  with  intense  constipation,  having  clay-colored  stools. 
In  one  instance,  in  which  two  children  in  one  family  were  constantly  fed 
on  modified  milk  of  varying  proportions,  the  formulae  were  changed  at  least 
a  half-dozen  times  with  the  usual  increase  of  fat  and  sugar  and  lowering  of 
the  proteids,  and  in  spite  of  this  fact,  after  repeated  trials,  and  no  benefit, 
this  feeding  method  was  abandoned.    A  child  recently  seen  by  the  author 


180  INFANT  FEEDING. 

did  not  gain  1  ounce  in  four  months.  This  was  one  of  the  reasons  that 
prompted  the  family  to  change  both  the  physician  and  the  food.  The  child, 
about  2  years  old,  was  very  pale,  restless  at  night,  quite  peevish  during  the 
da}'',  and  decidedly  backward  in  development.  It  could  neither  speak  nor 
walk,  although  the  teeth  were  well  developed.  From  the  time  the  modified 
milk  was  discontinued,  and  a  nitrogenous  diet  given,  the  infant  improved, 
and  from  last  reports  is  quite  well  developed. 

Do  not  let  us  blindfold  ourselves  with  the  belief  that  an  infant  is 
thriving  unless  our  baby  shows  a  regulanty  in  the  increase  of  weight,  sleeps 
well  at  night,  for  at  least  from  six  to  nine  hours  continuously ,  and,  above  all, 
assimilates  its  food,  as  evidenced  by  regular,  unaided  movements  of  the 
bowels;  such  movements  should  be  once  or  twice  in  twenty-four  hours,  have 
a  yellowish-white  color,  and  a  mustard-lilce  consistency.  If  the  stool  is  hard 
or  lumpy  or  pasty,  like  putty,  then  it  is  certainly  abnormal,  and  shows  im- 
proper food.  The  same  is  also  true  if  the  stool  contains  white  particles  of 
cheesy  curds,  showing  a  casein  indigestion.  In  one  infant,  which  had  taken 
modified  milk  continuously  for  seven  months,  an  obstinate  constipation  was 
only  relieved  after  full  doses  of  codliver-oil  and  extract  of  malt  were  given 
for  several  weeks — aided  by  massage,  besides  changing  the  diet. 

It  is  therefore  very  necessary  to  continually  watch  the  baby,  and  when 
abnormal  conditions  such  as  anaemia  prevail,  it  is  wise  to  give  restoratives 
for  a  long  period  in  addition  to  the  food.  Note  if  the  food  is  deficient 
in  its  nutritive  elements,  and,  if  so,  change  the  formula  so  as  to  adapt  it  to 
the  baby.  Do  not  give  medicine  when  the  quality  or  quantity  of  food  is 
deficient.    Remedy  the  food  first;  then,  if  not  satisfied,  give  medication. 

Pallor  of  the  Skin. — An  unusual  pallor  of  the  skin,  and  also  of  the 
conjunctival  mucous  membrane,  has  frequently  been  noticed  in  modified 
milk  babies.  In  one  instance  an  extreme  leucocytosis  was  noticed  for  the 
treatment  of  which  iron  was  given.  An  examination  of  a  drop  of  blood 
showed  a  diminution  of  the  red  blood-corpuscles  and  an  excess  of  the  white 
blood-corpuscles.  A  decided  hsemic  murmur  was  noticeable  in  the  vessels 
of  the  neck,  in  a  child,  two  years  old,  which  had  been  fed  continually  on 
modified  milk. 

Craniotabes,  softening  of  the  cranial  bones,  as  well  as  very  late  closing 
of  the  anterior  fontanel  has  also  been  observed  in  some  children  fed  with 
this  form  of  food. 

A  boy,  4  years  old,  a  typical  Wa-lker-Gordon  baby,  who  was  fed  exclusively 
on  modified  milk,  now  shows  knock-knees,  besides  having  been  under  the  treatment 
of  his  physician  for  a  general  furunculosis  of  the  scalp.  The  furuncles  were  of  such 
a  size  that  they  required  several  incisions;    others  opened  spontaneously. 

Sometimes  predigested  food  is  ordered  with  the  addition  of  peptogenic 
powder,  the  predigestion  to  be  done  at  the  laboratory.    A  great  many  phy- 


LABORATORY  MODIFICATION.  181 

sicians  who  formerly  condemned  percentage  feeding  have  become  converted 
to  this  method. 

Constipation,  which  is  frequently  encountered,  can  be  remedied  if  the 
chemical  and  clinical  causes  are  considered.  Superheated  milk  is  one  of  the 
main  causes.  In  spite  of  the  many  failures  reported  by  feeding  sterilized 
milk,  we  see  hundreds  of  babies  brought  up  on  this  line  of  feeding. 

Chemical  changes  are  produced  by  subjecting  the  mi'.k  to  a  tempera- 
ture of  213°  F.  for  thirty  minutes  and  frequently  forty-five  minutes.  These 
changes  take  place,  in  the  most  vital  elements  of  milk,  such  as  albuminate  of 
iron,  phosphorus,  and  possibly  in  the  fluorine.  These  elements  are  present  in, 
a  vitalized  form,  as  they  are  derived  from  tissues  that  contain  them.  When 
we  consider  that  children  require  phosphatic  and  ferric  proteids  in  a  living 
form,  then  we  cannot  continue  with  boiled  or  sterilized  milk-feeding  for  a 
too  prolonged  period  without  causing  structural  weakness. 

There  are  times  when  raw  milk  will  cause  too  frequent  stools;  then  it 
may  be  advantageous  to  resort  to  pasteurization  or  to  heating  the  milk  to 
167°  F.  for  about  twenty  minutes. 

I  am  convinced  that  prolonged,  sterilized  milk-feeding  will  result  in 
rickets.  I  have  had  many  cases  of  weak  spine  and  bony  structure  in  which 
nothing  but  improper  food  could  be  regarded  as  the  etiological  factor.  These 
children  were  among  the  well-to-do,  among  whom  excellent  hygiene  and 
proper  nursing  habits  were  rigidly  enforced.  Improvement  was  noted  when 
sterilized  milk  was  abandoned  and  raw  milk  food,  in  addition  to  raw  muscle 
juice,  grape  juice,  and  orange  juice,  was  prescribed. 

A  great  many  unsatisfactory  reports  are  heard  regarding  laboratory 
feeding.  Some  condemn  laboratory  feeding  because  it  is  patented.  Others 
condemn  the  method  after  noting  poor  results. 

More  recently  the  author  has  tried  raw  milk  and  cream  modified  at  the 
laboratory,  and  has  noted  a  great  difference  in  the  assimilation  of  such  modi- 
fied milk.  Thus,  while  some  experience  herein  reported  has  been  bad,  it 
is  possible  that  a  good  part  of  the  fault  is  due  to  overheating  the  milk. 
Changing  the  character  of  the  proteid  and  altering  the  chemical  relation- 
phip  of  the  various  ingredients  must  change  its  assimilability,  and  hence 
the  author  would  urge  those  who  use  the  laboratory  to  insist  upon  having 
formulaj  compounded  by  using  raw  milk  and  fresh  cream. 


CHAPTER  V  . 

OTHER  SUBSTITUTE  FOODS. 

Goats'  Milk. 

IIy  experience  with  goats'  milk  has  been  rather  good.  The  following 
case  will  serve  to  illustrate  the  manner  in  which  goats'  milk  was  used: — 

An  infant,  seven  months  old,  was  seen  by  me  in  consultation.  She  could  not 
digest  cows'  milk,  but  suffered  vomiting,  with  intestinal  colic,  and  had  cheesy  and 
cnrded  stools.  When  goats'  milk  was  given  in  the  same  quantity  as  cows'  milk,  the 
acute  indigestion  subsided. 

In  a  second  case^  an  infant,  one  month  old,  vomited  whenever  cows'  milk  was 
given,  and  suffered  with  dyspeptic  catarrh.  The  symptoms  subsided  when  the  infant 
was  put  to  the  breast  of  a  wet-nurse.  After  several  months  wet-nursing  the  infant 
was  again  given,  cows'  milk,  and  again  the  symptoms  returned.  As  we  could  not 
procure  a  wet-nurse,  goats'  milk  diluted  with  rice  watei',  using  four  ounces  of 
goats'  milk  with  four  ounces  of  rice  water,  and  one  teaspoonful  of  sugar,  was  gi\en. 
The  child,  six  months  old,  was  fed  once  every  thiee  hours.  After  one  week's  feeding 
we  increased  the  quantity  of  goats"  milk  to  five  ounces  and  decreased  the  rice  water 
to  three  ounces.  When  the  child  was  nine  months  old  pure  goats'  milk,  pasteurized 
for  ten  minutes  at  a  temperature  of  158°  F.,  was  fed,  with  very  satisfactory  results. 
The  child  gained  in  weight  and  had  yellowish  stools. 

Barbell ion^  has  for  years  been  an  ardent  advocate  of  the  introduction 
of  goats'  milk  for  infants  and  invalid  diet.  He  describes  tests  which  show 
that  the  coaguluin  is  soft  and  very  soluble^  like  that  of  human  and  asses' 
milk,  while  the  coagulura  from  the  cows'  milk  is  more  compact  and  difficult 
to  digest.  Comparative  tests  with  gasterin  showed  that  while  cows'  milk 
was  scarcely  affected  by  it  during  twenty  hours,  human,  goat,  and  asses' 
milk  were  completely  digested. 

He  reports  a  number  of  cases  showing  the  remarkable  manner  in  which 
infants  thrive  on  goats'  milk.  The  Academie  voted  in  favor  of  his  conclu- 
sions as  to  the  advisability  of  establishing  numerous  goat  milk  depots 
throughout  the  city.  One  of  the  ])rincipal  advantages  of  the  goat  for  this 
purpose  is  that  it  is  refractory  to  tuberculosis. 

BiTrKRMii.K  Fkddinc. 

A  very  elaborate  paper  on  the  subject  of  buttei-milk  feeding,  by  T)t. 
Teixeira  de  j\Iattos,  of  Eotterdam,  has   recently  appeared.-     He  cites  de 


^Goats'  ]\Iilk  for  Infant    Fc('<!ing.      r>ari)clli(iii    (i'aiis).      Jiulletin  de  I'Academic 
Medecine   (I'aris). 
^  Jahrbuch  fiir  Kiudcrhcilkunde,  January,  1902. 

(182) 


BULGARIAX  MILK.  183 

Jager,  who  puljlished  a  paper^  ret-ominending  this  form  of  feeding 
Karger;  Homviiig,-  and  private  and  jiuhlic  reports  of  Schlossmann, 
Heubner,  Soltniann,  Finkelstein,  de  ]\Iatt<is,  and  otliers. 

ButtennUli. — Tal-p  1  quart  (liicr)  of  huilcnnill- ;  add  1  even  iahJe- 
spooiiful  of  rice,  ivJtedf,  or  other  fejnr  des'uu  d  (dhenit  10  to  IS  grams) ;  heat 
the  mixture  over  a  small  gas  pre,  with  constant  stirring,  untit  it  has  tjoiled 
up  three  different  times  (rerpiiring  about  tieenty-five  minutes);  then  add 
.2  or  S  tahtespoonfuts  (about  70  to  90  grams)  of  cane  sugar  or  becM  sugar. 
It  is  better  to  -use  new  enameled  ware  or  agate  ware  for  preparing  this  food. 
The  food  as  above  prepared  assumes  a  yellowish  color. 

It  is  necessary  to  liavr  iridc  mouths  for  tJie  bottles  as  the  food  coagulates 
and  gets  lumpy,  in  which  event  it  would  require  occasional  shalang  to  bring 
the  thickened  iTort ion  to  the  proper  consistency. 

BuLGAEiAX  Milk. 

Milk  soured  with  either  a  pure  culture  of  the  lactic  acid  bacillus,  or 
tablets  containing  the  Bulgarian  bacillus,  must  not  be  confounded  with 
ordinary  Inittermilk.  By  the  action  of  the  lactic  acid  on  the  casein  of  the 
whole  milk,  one  transforms  the  casein  into  a  soluble  casein  lactate. 

IIoiv  to  Prepare. — Boil  the  milk  and,  when  cool,  skim  off  the  skin  that 
rises.  To  one  quart  of  boiled  milk  add  one  teaspoonful  of  pure  culture 
of  the  lactic  acid  bacillus,  or  one  taljlet  containing  siicli  bacillus,  made  by 
the  Fairchild  Brothers  &  Foster,  or  by  Park,  Davis  &  Co.  Set  this 
inoculated  milk  in  a  warm  place  for  twenty-four  to  forty-eight  hours. 
The  lumpy  mixture  must  then  be  thoroughly  shaken,  and  if  of  a  thick 
creamy  consistency  must  be  placed  in  a  refrigerator  to  retard  further 
souring. 

Graanboom,  in  his  book  on  ''Diseases  of  the  Digestive  Tract  in 
Children"  (lUOl),  states  that  he  also  is  very  much  impressed  with  the 
value  of  buttermilk  as  an  infant-food. 

De  jMattos  states  tliat  cliildren  so  fed  for  a  period  of  six  to  eight 
inonths  show  signs  of  rickets  or  late  dentition,  although  they  look  well 
and  appear  to  ])e  well  nourished.  Whether  other  methods  are  worse  he 
does  not  state. 

Lactic  acid  was  never  found  in  the  urine  of  infants  fed  either  with 
hictic  acid  oi-  its  salts.  'I'his  series  of  experiments  was  made  by  de  Mattos, 
and  the  results  were  corroborated  by  Houwing. 

The  amount  of  lactic  acid  present  in  buttermilk  has  been  carefully 
studied.    Kol)ertson,  a  chemist,  found  it  to  be: — 

Mininuini     0.09  per  cent. 

Maximum    0.45  per  cent. 

^  Nedorlandscli  'ryilscjiiift  voor  (icnocskuiidi.iichladeii,  October,  1895. 
2  Centnvlblatt  t'iir  tJynakologic,  51,  190. 


184  INFANT  FEEDING. 

De  Jager  believes  that  good  buttermilk  docs  not  conta'n  more  than  0.5 
per  cent. -of  free  lactic  acid.^  These  are,  liowever,  not  absolute  and  positive 
data,  but  really  individual  h3'potheses. 

Contrary  to  the  ideas  of  Munk,  Uffelmann,  and  Ewald  (who  fear  the 
use  of  food  containing  lactic  acid),  de  ]\Iattos  has  found  that  chronic 
enteritis  and  gastric  complaints  soon  improve  when  an  exclusive  buttermilk 
feeding  is  resorted  to.  Hayem  and  Lesage  regard  lactic  acid  as  entirely 
innocuous  for  nurslings.  According  to  the  above-named  investigators,  lactjc 
acid  is  not  toxic  for  infants.  They  gave  experimentally  15  to  20  grains  in 
divided  doses,  mixed  with  sugar,  without  seeing  any  detrimental  results. 
Jaworski^  found  no  trace  of  lactic  acid  in  an  infant's  stomach  one  hour 
after  administering  it. 

Kiel  maintains  that  lactic  acid  improves  digestion,  while  Duclaux' 
states  that  lactic  acid  is  a  valuable  astringent.  Heubner*  found  lactic  acid 
in  the  stomach  of  two  healthy  infants  (to  the  extent  of  O.IG  to  0.2  per  cent.). 
Marfan  (quoting  Zotow)  maintains  that,  when  lactic  acid  is  found  in  the 
stomach  of  infants,  it  is  always  a  pathological  factor. 

Buttermilk  in  its  crude  (raw)  state  is  certainly  antagonistic  to  other 
micro-organisms.  This  is  due  to  the  presence  of  lactic  acid  bacilli.  Eaw 
cows'  milk  possesses  bactericidal  properties,  but  buttermilk  is  much  more 
bactericidal.  The  latter,  sterilized  with  the  aid  of  steam,  showed  virulent 
typhoid  bacilli  nine  days  after  being  inoculated  with  the  same.  In  non- 
sterilized  huiiermillc  (raw  state)  virulent  typlioid  bacilli  lost  their  virulence 
after  two  days,  and  when  put  into  the  brooding  oven  lost  their  virulence 
after  twenty-four  hours.  The  bacillus  lacticus  of  Pasteur  and  Hueppe  seems 
■  to  be  identical  with  the  bacillus  lactis  aerogenes  of  Escherich,^  which  is 
found  in  the  upper  part  of  the  small  intestine. 

Jaworski  found  that  pepsin  is  more  readily  secreted  when  lactic  acid 
is  given  internally.  De  Mattos  states  that  he  has  never  met  with  a  case  of 
Barlow's  disease  among  infants  fed  with  buttermilk. 

Disagreeable  symptoms  are  frequently  encountered  for  the  first  few 
weeks  while  giving  buttermilk.  Such  are  frequent  vomiting  and  diarrhoea. 
These  are  not  contra-indications  for  feeding,  and,  notwithstanding  the 
presence  of  the  above-named  symptoms,  the  feeding  should  be  continued. 
If,  however,  the  symptoms  are  very  severe,  then  the  administration  of  astrin- 
gents— such  as  bismuth,  argent,  nitrate,  tannalbin,  or  ichthalbin — may  be 
required  for  temporary  relief. 

An  important  point  is  that  in  this  form  of  infant-feeding  the  large, 


*  Nederlandsch  Tydschrift  voor  Gcneeskundigebladen,  1899,  i,  S.  945. 
•Deutschee  Arcliiv  filr  klinische  Medicin,  Bd.  xxxvii,  L 

» "IMaladiea  de  I'Enfance,"  tome  ii,  p.  606. 
•".Tahrbuch  fOr  Kinderheilkunde,"  1891. 

•  "Die  Darmbacterien  des  Sauglings,"  Stuttgart,  1888, 


BUTTERinLK  FEEDING.  185 

thick^  cheesy  curds  so  commonly  met  with  in  dyspepsia  and  diarrhoeas  in 
feeding  with  cows'  milk  are  never  seen.  Children  thus  fed  seem  to  with- 
stand the  infectious  diseases  very  well.  A  point  worth  noting  is  that  when 
a  child  is  more  accustomed  to  buttermilk  feeding  the  change  to  sweet  milk 
will  cause  diarrhoea. 

When  we  find  that  the  weight  is  not  increased  and  we  desire  to  change 
to  sweet  milk,  the  latter  should  be  gradually  added  to  the  buttermilk  in- 
stead of  making  a  distinct  change  suddenly. 

Quality  of  the  Buttermilk. — This  is  the  most  important  part  of  our 
subject.  In  securing  our  food  we  must  be  sure  that  we  are  dealing  with 
honest  dairymen  whose  sole  object  is  to  deliver  what  is  demanded  for  weak 
infants.  Stale  combinations  made  by  the  use  of  left-over  centrifugal  milk 
or  skim-milk  or  spoiled  milk  which  cannot  be  used  otherwise  should  be 
inquired  into  and  rejected. 

Good  buttermilk  can  be  made  from  either  whole  milk  or  from  cream. 
In  Holland  buttermilk  is  made  by  pasteurizing  cream  in  Timpe's  apparatus 
and  then  inoculating  and  buttering  the  same  with  a  pure  culture  of  lactic- 
acid  bacillus.  In  order  that  raw  milk  will  yield  buttermilk  a  certain  per- 
centage of  acidity  must  be  present. 

The  usual  precautious  in  milking  (so-called  modern  stable  hygiene) 
must  be  observed  in  securing  milk  to  be  used  in  making  buttermilk.  The 
milk  should  be  received  in  sterile  vessels  and  rapidly  cooled,  and  should  then 
be  kept  in  cool  cellars  or  ice-coolers  having  a  low  temperature  (no  higher 
than  15°  or  20°  C.)  for  eighteen  to  twenty-four  hours.  It  is  necessary  to 
stir  the  milk  occasionally.  Eapidity  of  souring  can  be  assisted  by  adding 
sour  milk  or  by  inoculating  with  a  pure  culture  of  lactic-acid  bacilli.  No 
definite  rule  can  be  laid  down  as  to  when  buttering  takes  place;  empiric 
methods  must  decide  this  matter.  This  is  due  to  the  size  of  the  vessel  used 
and  the  influence  of  seasonal  changes,  and  also  the  amount  of  churning  it 
had  received.  Cows'  milk  which  contains  colostrum  or  which  is  bitter  is  not 
adapted  for  buttering. 

Butter  should  form  in  small,  pin-head-sized  particles  in  thirty  to  forty- 
five  minutes.  It  is  regarded  as  a  mistake  to  have  large  particles  of  the  size 
of  a  pea  or  larger,  and  dairymen  look  upon  such  buttermilk  with  suspicion. 
Buttermilk  in  general  contains  about  0.3  to  0.4  per  cent,  of  fat, 

Esclierich  states  that  the  fermentation  of  milk  is  due  to  the  splitting 
up  of  the  milk  sugar  whereby  lactic  acid,  0,  and  COg  are  formed  in  the 
intestine. 

Table  No.  36,  on  following  page,  is  instructive  in  showing  the  per- 
centage of  acidity  present  and  also  the  dill'erence  in  fat. 


186 


INFANT  FEEDING. 
Table  No.  36. 


Specific 
Gravily. 

Solids, 
Percentage. 

Fat. 

Acidity  According 
to  Soxhlet-Henkel. 

Sour  milk  before 
buttering 

1.029 

11.40 

2.8 

18.1 

Buttermilk 

1.029 

9.  GO 

0.5 

16.1 

There  is,  therefore,  a  difference  of  2  per  cent,  in  the  amount  of  acidity 
present  in  favor  of  buttermilk. 

An  important  point  is  to  overcome  the  lumps  usually  found  as  coarse 
coagula  in  buttermilk.  De  Mattos  advises  adding  flour — either  rice,  luheat, 
or  lentil — or  even  some  proprietai'y  infant  foods,  according  to  the  require- 
ments of  the  infant. 

This  is  merely  given  to  hold  the  flocculi  in  finer  form  and  to  prevent 
their  coagulation  into  lumps.  Dyspeptic  children  with  subnormal  digestive 
powers  should  receive  a  minimal  quantity;  thus,  an  even  tablespoonful, 
amounting  to  about  10  grams,  will  suffice. 

Addition  of  Sugar. — The  quantity  of  sugar  to  be  added  must  be  reck- 
oned empirically;  thus,  3  tablespoonfuls,  about  90  grams,  are  required  to 
each  liter  (quart)  of  buttermilk.    Earely  do  we  need  more  than  100  grams. 

Cane  sugar  or  beet  sugar  serves  best  for  sweetening.  Sugar  cannot  be 
found  in  the  urine  nor  in  the  fgeces  of  infants  fed  on  buttermilk  to  whigh 
sugar  was  added. 

The  results  which  might  be  expected  from  using  cane  sugar — such  as 
diarrhoea,  fermentation,  sour  eructations — are  totally  absent  in  using  butter- 
milk feeding. 

Stools. — The  average  buttermilk-fed  infant  has  no  more  than  one  or 
two  stools  daily.  They  are  more  or  less  solid  in  consistency  and  have  an 
alkaline  reaction.  It  would  be  incorrect  to  state  that  all  children  fed  with 
buttermilk  must  have  yellow  stools.  We  know  that  even  Uffelmann,  in  his 
studies  of  infant-stools,  states  that  breast-fed  infants  show  great  variations 
from  apparent  normal  stools  and  still  thrive.  We  also  know  that  bottle- 
fed  infants  reared  on  cows'  milk  have  no  definite  kind  of  stool  which  we 
could  call  a  standard  stool.  Still,  the  buttermilk  fed  infant  never  has  the 
coarse  casein  particles  in  the  faeces  that  we  see  very  frequently  in  the  stools 
of  infants  fed  on  cows'  milk. 

The  bacteriological  examination  of  the  faeces  made  by  inoculating 
gelatine  plates  with  diluted  faeces  showed: — 

1.  Liquefying  colonies  rendered  Loeffler's  nutrient  gelatine  strongly 
alkaline.  Inoculated  into  bouillon,  the  latter  remained  clear,  forming  a 
skim  on  the  surface.    Milk  was  not  coagulated  by  these  micro-organisms. 


LAHMANN'S  VEGETABLE  MILK.  187 

They  formed  spores,  generated  HjS,  and  can  therefore  be  identified  as  the 
bacillus  butyricus  of  Hueppe. 

2.  Non-liquefying  colonies  were  inoculated  into  milk  sugar  bouillon  and 
left  in  the  brooding  oven  over  eight  hours  at  37°  C.  All  tubes  so  treated 
were  turbid  on  standing  over  night;  this  fact  excludes  the  possibility  of  its 
being  the  bacterium  coli. 

Other  properties  were  found,  such  as:  fermentation  in  milk  sugar 
bouillon,  no  skim  forming  on  the  bouillon ;  indol  does  not  form  in  peptone 
solution  (bacterium  coli  would  form  indol)  ;  milk  turns  sour  but  slowly; 
no  NH3  formation. 

From  a  study  of  the  above  properties  we  conclude : — 

1.  Bacterium  coli  commune  must  be  excluded. 

2.  Bacterium  coli  lactici  (Hueppe)  (resp.  bacterium  lactis  aerogenes, 
Escherich),  must  be  identified. 

The  lactic  acid  bacillus,  found  in  boiled  as  well  as  raw  buttermilk,  loses 
its  potency  in  the  intestinal  canal  in  the  presence  of  the  bacillus  butyricus, 
(Hueppe) .  The  latter  germ  grows  in  overwhelming  numbers  and  renders  the 
intestinal  contents  rapidly  alkaline. 

An  interesting  point  is  that,  if  the  buttermilk  were  originally  very 
sour,  the  faeces  will  be  very  alkaline,  showing  how  weak  the  bacterium  acidi 
lactici  is. 

Feeding. — The  writer  has  seen  excellent  results  from  buttermilk  feeding 
in  atrophic  and  marasmic  children.  As  an  article  of  diet  during  convales- 
cence after  pneumonia  and  typhoid  fever  the  results  were  encouraging. 

Quantity  to  be  Fed. — Buttermilk  as  above  prepared  should  be  fed 
exactly  as  would  other  milk.  Four  ounces,  increased  to  5  or  6  ounces,  can 
be  fed  every  3  hours,  or  the  interval  may  be  prolonged  to  3  ^/o  or  4  hours. 
It  will  be  necessary  to  coax  the  child  in  the  beginning  with  this  new  form 
of  feeding,  owing  to  the  difference  in  the  taste  of  fresh  milk  and  butter- 
milk. 

Lahmann's  Vegetable  Milk. 

In  Europe,  and  recently  also  in  our  country,  the  feeding  of  infants  has 
been  enriched  with  a  new  product;  thus,  Dr.  Lahmann  believes  that  the 
great  panacea  is  feeding  infants  with  milk  which  he  designates  as  "vege- 
table milk."  It  resembles  a  thick  jelly,  and  is  made  by  Hewwel  &  Veithon, 
of  Cologne.  His  theory  consists,  in  brief,  in  substituting  nuts  and  almonds, 
which  are  rich  in  albumin  and  fat,  instead  of  cereals  to  dilute  milk,  his 
idea  being  that  an  emulsion,  which  is  digestible  and  supposed  to  be  rich  in 
albumin,  is  doubtless  better  than  pure  water  or  a  thin  starch  paste.  In 
order  to  add  food  salts,  which  are  not  supplied  by  this  means,  he  extracted 
them  from  leaf  vegetables,  which  are  rich  in  food  salts,  and  added  some 
sugar  syrup.  In  this  manner  he  claims  to  have  made  a  preparation  which 
he  states  is  chemically  equal  to  human  milk,  and  full  of  nutritive  value.    His 


188  INFANT  FEEDING. 

idea  is  that  the  interposition  of  plant-albumin  (conglutin)  particles,  which 
coagulate  with  difficulty  between  the  coagulating  casein  masses,  would  in- 
crease their  digestibility  by  breaking  them  up,  and  that  the  digestion  of  the 
plant  albumin  and  oil,  as  well  as  of  the  sugar  and  food  silts,  would  present 
no  difficulty. 

Stutzer,  of  the  University  of  Bonn,  reports  thus:  The  vegetable  milk 
is  distinguished  from  children's  food  by  the  absence  of  starchy  substances. 
In  common  with  Biedert's  cream  mixture,  the  vegetable  milk  contains  con- 
siderable quantities  of  fat  in  an  emulsified  condition.  It  differs  from  the 
cream  mixture  in  the  way  it  is  prepared,  and  in  its  other  qualities. 

Chemical  Analysis. 

Fat 34.72  per  cent. 

Plant-casein  and  similar  nitrogenous  constituents...  12.00  per  cent. 

Sugar  and  plant-dextrin  31.02  per  cent. 

Salts    1.64  per  cent. 

Water 20.G2  per  cent. 

My  own  personal  experience  has  been  rather  favorable  with  the  use  of 
the  vegetable  milk,  inasmuch  as  an  emulsion  of  almonds  and  nuts  was  used 
to  dilute  the  curd  of  cows'  milk.  Thus,  equal  parts  of  vegetable  milk  with 
cows'  milk  were  taken  by  an  infant  for  several  months,  and  it  was  very 
well  assimilated.  Not  only  did  the  child  gain  in  weight,  but  the  bowels 
were  in  a  fair  condition,  and  the  infant  remained  strong.  My  experience, 
however,  is  too  limited  to  give  a  positive  opinion. 

Gaertner  Mother  Milk. 

Several  years  ago  I  was  persuaded  to  use  Gaertner  milk  in  a  series  of 
cases.  The  milk  was  sold  in  tin  cans.  The  manufacturers  would  not  take 
the  advice  given  them,  to  use  fresh  milk  and  deliver  the  milk  in  clean  bottles 
daily.  Such  food  as  "milk  sealed  in  tin  cans"  cannot  be  recommended  for 
healthy  and  certainly  not  for  sick  infants. 

In  the  Medical  Record,  December  11,  1897,  I  published  a  paper  enti- 
tled "The  Clinical  Value  and  Chemical  Results  of  Gaertner  Mother  Milk."^ 
This  food  has  now  been  used  several  years  in  Europe,  and  is  the  out- 
come of  the  scientific  endeavors  of  Professor  Gaertner,  of  the  University  of 
Vienna.  The  first  paper  was  published  by  Gaertner  in  the  Therapeutisclm 
Wochenschrift,  May  5,  1895. 

A  few  months  before,  January,  1895,  Gaertner,  in  an  address  before 
the  Vienna  Scientific  Society,  explained  the  mode  of  preparation  and  the 
results  obtained  with   his  new  modification  of  cows'  milk,   for  such  the 

^  Those  interested  are  referred  to  my  paper,  entitled  "Gaertner  Milk,"  containing 
an  elaborate  chemical  report  by  Professor  Poole.  New  York  Medical  Record,  Decem- 
ber 11,  1897. 


GAERTNER  MOTHER  MILK.  189 

mother  milk  of  Gaertner  really  is.  Professor  Gaertner,  in  the  preparation 
of  his  food,  has  aimed  to  overcome  what  has  been  the  great  difficulty  in 
infant-feeding — namely :  to  reduce  the  excess  of  casein  by  a  scientific  process 
without  the  addition  of  chemicals. 

To  achieve  this  result  he  employs  a  machine  called  a  separator  or 
rfannhaiiser  centrifuge,  which  makes  4000  or  8000  revo^.utions  per  minute. 
The  apparatus  consists  essentially  of  a  drum  of  steel,  which  revolves  on  its 
axis.  This  drum  is  filled  with  equal  parts  of  fresh  cows'  milk  and  sterilized 
water.  The  mixture  contains  approximately  the  same  amount  of  casein  as 
human  milk,  for  cows'  milk  undiluted  contains  about  twice  as  much  casein 
as  human  milk.  The  mixture  is  next  poured  into  the  centrifuge  and  the 
speed  of  the  drum  is  carefully  regulated,  so  as  to  separate  the  mixture 
contained  therein  into  (1)  a  creamy  (fatty)  milk  and  (2)  a  skimmed  milk. 
The  two  portions  so  separated  are  then  led  off  separately  by  suitable  open- 
ings in  the  centrifuge. 

The  analysis  of  each  of  these  portions  shows  that  the  creamy  milk  has 
the  same  quantity  of  fat  as  is  found  in  human  milk,  while  about  3  per  cent, 
of  the  casein  is  contained  in  the  skim  milk,  and  the  remainder,  about  1.7 
per  cent.,  remains  in  the  creamy  milk.  The  chemical  composition  of  fat 
milk  is  shown  in  the  following  table: — 

Table  No.  37. 

Proteio 

Fat  milk 1.7G 

Human  milk 1.03 

Cows'  milk,  diluted  witli  one-half  water. .   1.76 

If,  now,  3  or  4  grams  of  milk  sugar  be  added  to  every  100  cubic  centi- 
meters of  fat  milk,  the  percentage  of  sugar  is  brought  up  to  the  level  of  sugar 
in  human  milk.  This  addition  is  made  before  sterilizing.  The  fat  milk 
has  the  advantage  over  the  diluted  milk  of  having  "a  higher  percentage  of 
fat;"  it  also  curdles  more  slowly  than  diluted  milk  and  the  curd  forms  a 
more  flocculent  precipitate. 

Baginsky^  mentions  Gaertner  milk  as  a  new  form  of  food  introduced. 
In  our  country  Jacobi^  states  that  Gaertner  milk  is  applicable  to  the  ma- 
jority of  infants  who  require  cows'  milk  appropriately  prepared.  A  few 
years  ago  I  subjected  the  milk  to  a  very  rigid  test  from  June  to  October,  the 
worst  months  for  milk  digestion.  The  hygienic  conditions  of  the  infants 
were  those  found  in  the  average  tenement  house,  too  well  known  to  need 
description. 

The  guides  for  ascertaining  the  degree  of  assimilation  were  the  follow- 
ing factors : — 

1.  The  child's  general  condition,  as  manifested  by  its  appearance,  ap- 
petite, and  sleep. 


Fat. 

Sugar. 

Ash. 

3  3.5 

2.5 

0.35 

3.5 

7.03 

0.21 

1.6 

2.5 

0.35 

*"Lfhrbuch  der  Kindorkranklieiten,"  fifth  edition,  pages  35  and  30. 
•  "TLerapeutics  of  Infancy  and  Childhood,"  page  50S. 


190  INFANT    FEEDING. 

2.  The  presence  or  absence  of  gastro-enteric  disturbances,  such  as  vom- 
iting, colic,  restlessness. 

3.  The  condition  of  the  stools,  constipation  or  diarrhoea,  the  number 
of  stools  in  twenty-four  hours. 

4.  The  gain  in  weight;  weekly  observations. 

The  nurses  or  mothers  were  instructed  to  note  the  amount  of  food  taken 
and  the  number  of  stools  in  twenty-four  hours. 

We  submitted  the  stools  passed  in  twenty-four  hours  to  Mr.  Herman 
Poole,  our  chemist,  whose  chemical  report^  is  of  interest.  We  tried  to  ascer- 
tain how  much  proteids,  fat,  sugar,  and  salts  were  taken,  how  much  absorbed, 
and  how  mnch  was  voided  in  the  faeces  after  having  taken  part  in  metab- 
olism. 

Backhaus's  Milk. 

The  following  method  is  employed  in  the  production  of  this  food. 
The  milk  from  different  breeds  of  cows  is  mixed  and  passed  through  a  cen- 
trifuge, to  separate  the  cream  from  the  milk  and  to  remove  any  impurities 
that  might  have  gained  access  to  the  milk,  notwithstanding  the  great  care 
used  in  handling.  Three  grades  are  produced :  two  for  infants,  the  third 
representing  full  milk  in  its  composition.  After  separating  it  from  the 
cream  the  milk  is  exposed  to  the  action  of  a  mixture  of  rennet,  trypsin,  and 
sodium  carbonate,  which  are  combined  in  such  proportions  that  the  trypsin 
will  have  converted  at  the  end  of  thirty  minutes  30  per  cent,  of  the  casein 
into  soluble  albumin.  By  this  time  the  action  of  the  rennet  coagulates  the 
balance  of  the  casein  and  thus  arrests  the  action  of  the  trypsin.  The  tem- 
perature of  the  mixture  is  now  raised  to  80°  C.  (176°  F.)  by  the  introduc- 
tion of  steam  into  it.  At  this  temperature  it  is  kept  for  five  minutes.  At 
the  end  of  this  time  it  is  strained  through  cloths  and  mixed  with  half  its 
volume  of  water,  one-fourth  its  volume  of  cream,  and  the  necessary  amount 
of  sugar  of  milk.  It  is  finally  put  up  in  bottles  holding  135  grams  (about 
4  ounces)  and  sterilized. 

The  second  grade,  for  older  children,  is  obtained  by  mixing  equal 
parts  of  milk  and  water  with  half  the  quantity  of  cream  and  with  milk 
sugar.    This  is  put  up  in  quantities  of  200  grams  (about  6  Vg  ounces). 

The  third  grade,  in  bottles  holding  300  grams  (about  10  ounces),  rep- 
resents cows'  milk  in  composition,  modified  by  the  above-mentioned  process. 
The  composition  of  the  three  grades  is  given  as  follows: — 

Fat 3.1  3.2  3.3 

Sugar  of  milk  G.O  6.4  4.8 

Casein  0.6  1.8  3.0 

Albumin   10  0.3  0.5 

Ash 0.4  0.4  0.7 

*New  York  Medical  Record  December  11,  1897. 


CONDENSED  MILK— CONDENSED  CREAM.  191 

The  milk  has  been  tried  at  the  Wiener  allgemeine  Poliklinik  by  Friih- 
wald  in  a  series  of  twenty  cases,  the  histories  of  which  are  given  by  the  au- 
thor. With  the  exception  of  six,  these  children  have  been  under  observation 
for  more  than  two  months.  When  first  seen  the  children  were  all  suffering 
from  different  forms  of  digestive  disturbances,  and  from  malnutrition; 
some  were  suffering  from  severe  marasmus,  and  most  of  them  passed  through 
some  other  disease  while  they  were  under  observation.  Three  of  the  infants 
took  the  breast  in  addition  to  the  Backhaus  milk  for  periods  of  two  and  three 
weeks,  when  they,  too,  had  to  be  put  on  the  artificial  milk  entirely.  The 
children  took  about  six  bottles  of  No.  1  up  to  four  weeks,  seven  to  eight  to 
the  end  of  the  second  month.  From  the  middle  of  the  third  month  the 
second  grade  was  gradually  substituted,  while  No.  3  was  used  only  in  the 
case  of  an  older  child.  A  daily  gain  was  observed  of  from  18  to  30 
grams  (about  ^/o  to  1  ounce).  In  private  practice  and  in  healthy  children 
a  gain  of  50  grams  (about  1  Vj  ounces)  not  rarely  happens.  The  milk 
keeps  well. 

Condensed  Milk  or  Condensed  Cream. 

Hundreds  of  infants  are  fed  with  condensed  milk.  This  has  its 
rciisons : — • 

1.  The  readiness  with  which  condensed  milk  is  obtained. 

2.  The  great  cheapness  of  this  article. 

3.  The  ease  with  which  the  feeding  mixture  can  be  prepared. 

Jacobi  says  that  some  manufacturers  use  pure  cows'  milk;  others  find 
it  in  accordance  with  the  health  of  their  bank  accounts  to  use  skimmed  milk. 

Quantity  of  Sugar  in  Condensed  Milk. — Milk  sold  in  our  city  for  im- 
mediate use  contains  about  12  to  15  per  cent,  of  sugar.  Milk  to  be  kept  for 
an  indefinite  time  contains  as  much  as  50  per  cent,  of  sugar.  These  varia- 
tions show  how  serious  it  is  to  use  the  same  quantity  of  condensed  milk  all 
the  time  and  from  different  sources  with  such  an  enormous  variation  in  the 
quantity  of  sugar. 

Kehrer — quoted  by  Jacobi — states,  regarding  it,  that  it  increases  the 
formation  of  lactic  acid.  Fleischman  states  that  it  gives  rise  to  thrush  and 
diarrhoea;  Daly,  that  it  fattens  them  (?),  but  gives  rise  to  rachitis. 

The  worst  specimens  of  rachitis  and  spinal  rickets  seen  in  my  clinic 
are  in  condensed-milk  babies.  Our  medical  literature  reports  many 
cases  of  apparent  health  in  infants  fed  on  condensed  milk.  It  has  led  Des- 
sau, with  a  large  experience  with  infants,  to  mention  such  a  method,  al- 
though he  advocates  cows'  milk,  properly  modified,  for  continued  use.^ 

In  traveling,  when  good  fresh  cows'  milk  cannot  be  obtained,  then  I 
permit  the  use  of  condensed  milk,  but  for  a  few  days  or  for  a  week  only, 
as  on  the  ocean  steamer,  where  cows'  milk  cannot  be  had. 


'  See  my  paper  on  infant-fpcding  (read  before  the  Society  for  Medical  Progress, 
April  11,  189G),  published  in  extenao  in  Pediatncs  for  July  15,  1896. 


192 


INFANT  FEEDING. 


My  experience  among  thousands  of  children  seen  in  my  Children's 
Service  at  the  German  Poliklinik  and  also  at  the  service  at  the  West-Side 
German  Dispensary  during  these  last  fifteen  years  has  been  that  children 
so  fed  have  rickets;  that  they  are  predisposed  to  the  infectious  disorders; 
that  they  have  less  resistance  and  far  less  vitality,  especially  in  combating 
such  diseases  as  pneumonia  or  diphtheria;  that  they  have  tendencies  to 
hernias  and  deformities,  owing  to  the  softer  condition  of  their  muscles  and 
bones;  that  they  invariably  suffer  with  constipation,  alternating  with  diar- 
rhoea; that  their  dentition  is  delayed,  compared  with  other  methods  of 
hand  feeding.  Thus  summing  it  up,  I  cannot  approve  of  this  method  at 
all. 

Condensed  cream  will  be  lauded  by  the  mother  whose  baby  is  well,  and 
again  the  same  food  will  be  condemned  by  the  mother  of  an  infant  whose 
rickety  head,  bones,  and  muscles  are  founded  on  an  impoverished  diet  of 
condensed  milk.  We  can  account  for  the  rickety  child,  but  we  cannot 
account  for  the  healthy  one  on  the  same  food. 

The  directions  on  the  tin  of  the  Anglo-Swiss  Condensed  Milk  Com- 
pany's Milkmaid  Brand  of  condensed  milk  are,  for  new-born  infants,  add 
14  parts  of  water;  as  the  child  grows  older,  gradually  use  less  water,  but 
never  less  than  7  parts. 

The  analyses  of  all  these  condensed  milks  are  of  the  milk  diluted  with 
with  7  parts  and  14  parts  of  water — the  two  extremes. 

The  following  brands  of  condensed  milks  are  considered  to  be  among 
the  best  upon  the  market. 

Table  No.  38, 


Milkmaid  Brand. 

Gail-Borden  Eagle 
Brand. 

Nestle's  Siviss  dlilk. 

Womaii^s 
Milk. 

With  7 

With  14 

With  7 

With  14 

With  7 

With  14 

PartsWater. 

Parts  Water. 

Paris  Water. 

PartsWater. 

PartsWater. 

PartsWater. 

Water  .   .    • 

88.18 

93.09 

89.10 

94.09 

87.95 

93.46 

88.51 

Ash           .    . 

0.36 

0.19 

0.29 

016 

0  25 

0.14 

0.34 

Proteids   .    . 

1.50 

0.82 

1.3L 

0.71 

1,51 

0.82 

2.35 

Fat    ...    . 

1.70 

0.92 

1.18 

0.64 

2.14 

1.16 

2.41 

Cane-sugar  . 

6.00 

3.25 

6.59 

3.57 

5.81 

3.15 

Milk-sugar  . 

2.26 

1.23 

1.53 

0.83 

2.34 

1.27 

6.39 

On  studying  the  clinical  relationship  of  the  component  parts  of  con- 
densed milk,  it  is  very  apparent  that  diluting  the  Eagle  brand  of  condensed 
milk  with  14  parts  of  water,  we  have  but  0.7  per  cent,  of  proteid,  0.6  per 
cent,  of  fat,  and  3.5  of  sugar.  The  deficient  bone-building  and  muscle- 
forming  ingredients  accounts  for  the  rachitis  which  invariably  results. 


CHAPTER  VI. 
PROPrjETARY  INFANT  FOODS. 

Patent  Foods. 

There  are  a  great  many  infant  foods  in  use  at  the  present  time.  No 
one  will  question  the  large  amount  of  foods  sold.  This  is  due  to  several 
reasons:  First,  because  the  laity  have  been  educated  to  use  them,  vehen 
cows'  milk  or  even  when  breast-milk,  in  rare  instances,  disagrees;  second, 
physicians  of  large  experience  advocate  the  use  of  a  great  many  patent  foods. 
When  disturbances  in  the  stomach  or  intestines  interfere  with  the  proper 
digestion  and  assimilation  of  the  proteids,  then  frequently  the  modification 
of  the  milk,  by  the  addition  of  these  foods,  yields  good  results.  In  some 
instances  where  there  is  no  appetite  we  frequently  can  stimulate  an  appetite 
by  advocating  the  temporary  use  of  these  foods. 

In  the  large  cities  where  breast-milk  is  unobtainable  for  infants,  these 
foods  are  frequently  given. 

During  the  course  of  summer  complaint,  typhoid  fever,  or  acute  infec- 
tious diseases,  I  have  frequently  advised  the  use  of  diluted  milk  with  several 
teaspoonfuls  of  a  nutritious  food,  rich  in  barley  malt.  The  objectionable 
features  of  patent  foods  consist  in  the  ease  with  which  they  are  procured, 
and  the  careless  manner  in  which  they  are  given.  Thus,  a  large  portion  of 
the  laity  will  follow  the  directions  on  the  label  of  the  box  of  patent  food 
to  the  detriment  of  the  child.  Many  a  case  of  rickets  or  scurvy  can  be  traced 
to  ignorance  in  giving  patent  foods.  We  know,  however,  that  there  are  some 
virtues  in  these  patent  foods,  and  to  attribute  all  cases  of  rickets  or  scurvy 
to  this  one  cause  is  wrong.  Investigations  made  by  the  American  Pediatric 
Society  showed  that  a  large  number  of  children  fed  on  sterilized  milk  suf- 
fered with  scurvy.  A  great  many  facts  must  therefore  be  considered  before 
condemning  or  praising  one  or  all  of  the  foods.  The  intelligent  physician 
knows  that  raw  milk  or  milk  warmed  to  blood  heat  possesses  anti-scorbutic 
properties.  When  a  given  commercial  food  is  added  to  raw  milk,  thoroughly 
mixed,  and  heated  to  blood  heat  or  to  a  pasteurizing  temperature,  we  still 
retain  the  virtues  of  the  milk  and  increase  its  nutritive  value  with  the  aid 
of  the  food  selected.  Eoughly  speaking,  there  are  two  kinds  of  infant  foods 
on  the  market:  (a)  Infant  foods  to  be  used  as  adjuncts  to  fresh  cows'  milk. 
(b)  Infant  foods  in  which  desiccated  cows'  milk  is  a  constituent. 

These  foods  are  commonly  known  as  dried-milk  foods,  although  in  this 
class  of  foods  milk  solids  constitute  but  from  one-eighth  to  one-fourth  tlie 
substance  of  the  foods,  the  balance  consisting  of  matters  derived  from 
cereals.  In  some  of  these  foods  the  starch  of  the  cereals  is  un transformed, 
and  they  may  be  termed  farinaceous  dried  milk  foods.    In  others  the  starch 

"  (193) 


194  INFANT  FEEDING. 

of  the  cereals  has  been  transformed  into  dextrin  and  maltose,  and  they  may 
be  termed  malted  dried  milk  foods. 

All  attempts  to  preserve  whole  cows'  milk  by  evaporating  it  to  dryness 
have  been  failures ;  the  fat  of  desiccated  milk  soon  acquires  a  rancid  flavor, 
and  the  caseous  matter  does  not  properly  dissolve  in  water,  as  the  drying 
process  destroys  its  colloidal  condition.  In  the  dried  milk  foods  the  caseous 
matter  of  the  cows'  milk  is  intimately  mixed  with  the  other  ingredients, 
but  its  colloidal  condition  has  been  destroyed,  and  it  is  in  the  form  of  fine, 
hard,  granular  particles,  very  sparingly  soluble  in  water. 

The  group  of  infant  foods  used  as  adjuncts  to  cows'  milk  are  either 
farinaceous  foods,  made  from  cereals  and  consisting  largely  of  unconverted 
starch;  or  malted  foods,  also  made  from  cereals,  but  having  the  starch 
transformed  into  soluble  maltose  and  dextrin.  As  fresh  cows'  milk  is,  with- 
out doubt,  the  best  generally  available  material  for  the  artificial  feeding 
of  infants,  the  foods  of  the  latter  class,  used  for  the  modification  of  fresh 
cows'  milk,  are  more  in  accord  with  physiological  principles  than  are  the 
dried  milk  foods. 

Of  the  large  number  of  infant  foods  that  have  been  put  on  the  market, 
it  is  our  purpose  to  describe  a  few  commonly  known  foods.  In  order  to 
judge  fairly  of  the  nutritive  value  of  an  infant  food  and  its  resemblance 
to  woman's  milk,  it  is  necessary  to  know  its  composition  after  its  preparation 
for  the  nursing-bottle  according  to  the  directions  of  its  manufacturer,  and 
the  analyses  that  accompany  the  following  descriptions  are  of  the  foods 
prepared  for  use  for  infants  six  months  of  age  as  per  directions  on  the 
packages. 

List  op  Infant  Foods. 

The  following  list  of  infant  foods  is  quite  complete,  although  there  are 
but  four  or  five  foods  that  are  used  in  any  quantity;  the  balance  having 
a  small  demand. 

Blair's  Wheat  Food  (cereal  food;   baked  wheat). 

Hubbel's  Wheat  (cereal  food;   baked  wheat). 

Wampole's  Milk  Food  (composed  of  predigested  cereals,  beef  and 
milk). 

Wyeth's  Prepared  Food  (composed  of  malt  milk  and  cereals). 

Just's  Food  (partially  predigested  cereals.    To  be  used  with  milk). 

Malted  Milk  (malted  and  containing  dried  milk). 

Horlick's  Food  (predigested,  to  be  added  to  milk). 

Mellin's  Food  (predigested,  to  be  added  to  milk). 

Imperial  Granum  (baked  wheat). 

Nestle's  Food  (composed  of  cereals  partially  predigested  and  dried 
milk), 

Lacto-Preparata  (dried  milk). 

Lactated  Food  (farinaceous  with  milk  sugar). 


NESTLirS  FOOD.  195 

Ridge's  Food  (farinaceous). 

Peptogenic  Milk  Powder  (to  modify  milk). 

Pegnin  (also  used  to  modify  tlie  casein  of  cows'  milk). 

Zimmerman  Barley  Oat  Pood  (cereal). 

Nutrico  Food  (cereal). 

Lange's  Tissue  Food  (a  condensed  milk). 

Hayes's  Oat  Food  (cereal). 

Allenbury's  Milk  Food,  No.  1  (predigested;  prepared  with  water, 
contains  dried  milk). 

Allenbury's  Milk  Food,  No.  2  (predigested;  prepared  with  water, 
contains  dried  milk). 

Allenbury's  Malted  Food,  No.  3  (partially  predigested;  prepared  with 
milk). 

Benger's  Imported  (cereal  and  not  predigested). 

Neave's  Food,  Imported  (farinaceous), 

Eskay's  Albuminized  Food. 

Cereal  Milk. 

Carnrick's  Soluble  Food. 

Diastased  Farina. 

Coombs's  Malted  Food. 

Pobinson's  Groats. 

Eobinson's  Patent  Barley. 

Chapman's  Whole  Flour. 

Scott's  Oat  Flour. 

Milkine. 

The  published  analyses  of  woman's  milk  show  the  great  variability  of 
its  composition,  especially  as  regards  the  percentage  of  proteids  and  fats. 
The  analysis  of  woman's  milk  used  in  the  following  tables  is  by  Dr.  Luff, 
adopted  as  the  standard  by  Cheadle,  It  agrees  closely  with  Leed's  analysis, 
excepting  as  to  the  fat,  which  is  given  by  Luff  as  2.41  per  cent,  and  by 
Leeds  as  4.13  per  cent. ;  the  latter  amount  seems  too  large,  as  it  exceeds 
considerably  the  published  averages  of  a  number  of  observers. 

Nestle's  Food. 

Nestle's  food  is  a  farinaceous  dried  milk  food.  According  to  the  manu- 
facturers, it  is  made  "from  the  richest  and  purest  cows'  milk,  the  crust  of 
wheaten  bread,  and  cane  sugar,"  and  is  a  "form  of  modified  milk."  "No 
cows'  milk  is  to  be  added  to  Nestle's  food;  nothing  but  water,  and  that  water 
is  boiled." 

Upon  examination,  unconverted  starch  and  cane  sugar  are  found  to  be 
its  principal  constituents,  amounting  to  about  70  per  cent,  of  the  whole. 
The  directions  for  preparing  Nestle's  food  for  the  nursing  bottle,  for  in- 
fants six  months  old,  are  to  use  2  level  tablcspoonfuls  of  the  food  to  V, 


196  INFANT  FEEDING. 

pint  of  water;  mix  ilie  food  willi  ciioiinh  wai'iii  walor  to  make  a  smooth 
l)ast('  that  will  ])(»ur,  add  the  rest  of  llio  walci'  and  Ixiil  in  a  saucepan,  stir- 
ring constantly  nntil  it  thickens  and  a  uiilkv  i'tiain  appears  on  the  top. 

Tablk  iSo.  ;jn. 

Composition  of  Xrsi1c\s 
Food.^  irhcn  Pre- 
pared as  above.  Woman's  Milk, 

Water   92.70  '  88..51 

Salts    0.13  0.34 

Proteids    0.81  2.35 

Fat 0.36  2.41 

Starch  1.99 

Cane-sugar   2.57 

Maltose,  dextrin,  etc    0.44 

INIilk-sngar    0.S4  G.39 

Reaction  alkaline.  Reaction  alkaline. 

The  mixtnre  owes  its  thick  condition  niainl}'  to  tlie  insoluble  starch 
present.  The  total  carbohydrates  therein  (5.84  per  cent.)  are  somewhat 
less  than  the  carbohydrate,  milk  sugar  (G.39  per  cent.),  in  woman's  milk; 
it  is  to  be  noted  that  of  this  amount  1.99  per  cent.,  or  about  one-third, 
consists  of  insoluble  starch. 

The  fat  is  nearly  one-sixth  and  the  proteids  are  about  one-thir(.l  of 
the  amounts  in  woman's  milk,  and  over  one-half  of  the  proteids  is 
insoluble,  owang  to  the  colloidal  condition  of  the  milk-casein  having  been 
destroyed  by  drying  during  manufacture. 

Horlick's  ]\Ialted  ]\Iilk. 

This  is  a  dried  milk  food,  said  to  be  composed  of  pure,  rich  cows' 
milk  combined  with  the  extract  of  malted  grains,  and  not  to  require  the 
addition  of  milk,  nor  any  cooking.  The  manufacturers  claim  that  by 
their  methods  ami  apparatus,  the  proteids  are  reiulered  very  digestible 
and  do  not  form  large,  irritating  curds  in  the  stomach. 

The  directions  for  preparing  the  food  for  an  infant  six  months  old, 
are  to  dissolve  3  to  4  heaping  teaspoonfuls  .in  41/4  to  G  ounces  of  water. 

Table  No.  40. 

norlick's  Malted  Mill:.       Woman's  Milk. 

Water    80.29  88.51 

Salts    0.5.3  0.34 

Proteids    2.31  2.35 

Fat   1.24  2.41 

('arl)oliydrates    n.dl  0.39 

This  product  is  very  nearly  solul)le  in  water,  as  its  ])rin('i])al  con- 
stituents   are    the    soluble    carbohydrates — maltosC;,    dextrine^,    and    milk 

1  Accordinc;  to  Chittenden. 


MILKINE.  -ig>y 

sugar.  The  drying  process  is  said  to  be  conducted  very  carefully  in  a 
vacuum,  and  hence  tne  solubility  and  digestibility  of  the  product,  it  is 
claimed,  are  not  lessened. 

The  proteids  are  about  the  same  as  in  woman's  milk,  luit  the  fat  is 
al)out  three-fifths  and  the  carbohydrates  are  about  five-thirds  as  much  as 
woman's  milk. 

When  cows'  milk  causes  continued  constipation,  the  substitution  of 
a  bottle  containing  hot  water  S  ounces,  in  which  -t  teaspoonfuls  of  malted 
milk  are  dissolved,  are  indicated.  It  acts  as  a  corrective,  as  the  maltose 
has  a  laxative  effect. 

MiLKIXE. 

This  is  a  malted  dried  milk  food.  Its  makers  state  it  is  a  complete 
food  ready  for  immediate  use  by  the  addition  of  water,  and  the  only  pre- 
pared food  that  combines  the  nutritive  elements  of  meat,  milk,  and 
cereals. 

Jn  this  malted  dried  milk  food,  beef  extract  is  combined  with  cereal 
extractives  and  dried  milk.  Soluble  carbohydrates  are  its  principal  constit- 
uents, forming  nearly  three-fourths  of  the  product.  The  proteids  are  spar- 
ingly soluble. 

The  directions  for  preparing  milkine  for  an  infant  three  to  six  months 
of  age  are  to  dissolve  1  to  2  dessertspoonfuls  of  food  in  a  breakfastcupful  of 
water. 

Composition  when  prepared  with  2  dessertspoonfuls  in  a  breakfast- 
cupful  of  water : — 

Table  No.  41. 

Milkine.  Woman's  Milk. 

Water    92.78  88..51 

Salts    0.23  0.34 

Proteid.s    0.92  2.35 

Fat    0.43  2.41 

•IMaltose,  dextrin,  eti- 4.74 

Milk-sugai-   0.00  6.39 

Reaction  alkaline.     Reaction  alkaline. 

Tlie  total  solids  are  liai'dly  two-tbirds  of  the  amount  in  woman's  milk. 
'J'he  fat  esj)ecially  is  greatly  deficient,  being  only  about  one-sixth  of  the 
amount  in  woman's  milk,  and  the  })rotei(ls  are  but  two-lifths  of  the  amount 
in  woman's  milk. 

A  dilution  of  1  ])art  of  good  rows'  milk  with  about  ]  parts  of  water  will 
contain  about  the  same  amount  of  milk  as  milkine  prepared  as  above. 

Ceukal  Milk. 
Cereal  milk  is  a  malted  dried  milk  food.     It  is  stated  1)y  its  makers  to 
be  a  complete  food,  cooked  and  ready  for  use  with  the  simple  addition  of 


198  INFANT  FEEDING. 

water,  and  to  be  made  from  the  purest  Vermont  dairy  milk,  the  finest 
wheat  gluten  flour,  the  best  barley  malt,  and  milk  sugar. 

Cereal  milk  in  general  appearance  very  much  resembles  the  other 
malted  dried  milk  foods,  but  it  contains  a  much  greater  percentage  of  milk 
sugar,  showing  that  this  substance  is  used  in  its  manufacture,  as  claimed. 

The  directions  for  preparing  it  for  use  are  to  mix  1  teaspoonful  of 
cereal  milk  in  a  teacupful  of  hot  water  for  infants  under  three  months  of 
age  or  for  a  very  delicate  child. 

Preparation  for  a  child  six  months  old: — 

"To  make  6  ounces  Prepared  Food,  use  3  Vi  rounding  teaspoonfuls  Cereal  Milk 
Powder,"  as  directed. 

Composition  when  prepared : — 

Table  No.  42. 

Cereal  Milk.        Woman's  Milk. 

Water    90.98  8G.73 

Total    solids 9.02  13.26 

Fats   0.38  4.13 

Proteids    1.09  2  00 

Inorganic    salts 0.21  0.20 

Carbohydrates    7.34  6.93 

The  reaction  to  litmus  was  neutral,  or  faintly  acid.  The  food  contains 
starch.  No  white  of  egg  or  cream  was  added,  since  neither  is  definitely  pre- 
scribed. This  fact  may  be  taken  into  consideration  when  comparing  the 
analysis  with  that  of  the  other  foods. 

The  total  of  soluble  carbohydrates  as  above  is  practically  the  same  as 
in  woman's  milk;  the  amount  of  proteids  is  less  than  one-half  the  amount 
in  woman's  milk,  and  about  one-half  is  insoluble  in  water.  The  amount  of 
fat  is  one-eleventh  the  amount  in  woman^s  milk.  The  small  amount  of  fat 
indicates  that  the  cereal  extractives  and  milk  sugar  make  up  the  bulk  of  the 
solids  of  this  food,,  and  that  a  dilution  of  1  part  of  good  cows'  milk  with  11 
parts  of  water  would  be  the  counterpart  of  the  above  mixture  as  to  the 
amount  of  milk  therein. 

Wampole's  Milk  Food. 

Wampole's  milk  food  is  a  malted  dried  milk  food.  Its  makers  state 
that  it  is  made  from  malted  cereals,  beef,  and  milk,  and  when  mixed  with 
warm  water  it  is  immediately  ready  for  use;  no  other  preparation  neces- 
sary. 

This  dried  milk  food  is  very  nearly  soluble  in  water,  owing  to  the  solu- 
ble carbohydrates  being  so  large  a  constituent.  A  little  less  than  one-half 
of  the  proteids  is  insoluble  in  water.  A  small  amount  of  beef  extract  has 
been  combined  with  the  cereal  extractives  and  dried  milk. 


IMPERIAL  GRANUM.  199 

"  To  prepare  it  for  an  infant  six  months  to  1  year  of  age,  the  directions 
are  to  dissolve  4  to  6  teaspoonf uls  of  the  food  in  6  ounces  of  hot  water.  Com- 
position when  prepared  by  dissolving  6  teaspoonfuls  in  6  ounces  of  water : — 

Table  No.  43. 

Wampole's  Milk-food.  Woman's  Milk. 

Water    88.59  88.51 

Salts  0.46  0.34 

Proteids  1.58  2.35 

Fat    0.73  2.41 

Maltose,  dextrin,  etc 7.65 

Milk-sugar 0.99  6.39 

Reaction  alkaline.  Reaction  alkaline. 

Compared  with  woman's  milk  it  is  seen  that  the  carbohydrates  are 
considerably  in  excess,  and  the  proteids  and  fat  are  deficient,  the  fat  espe- 
cially, it  being  less  than  one-third  the  amount  in  woman's  milk. 

One  part  of  good  cows'  milk  diluted  with  about  3  ^/^  parts  of  water 
would  be  analogous  to  the  dilution  of  milk  in  Wampole's  milk  food  pre- 
pared as  above. 

Imperial  Granum. 

Imperial  granum  is  a  farinaceous  food  to  be  used  as  an  adjunct  to  cows' 
milk. 

Its  makers  state  that  it  is  a  solid  extract  derived  from  very  superior 
growths  of  wheat,  nothing  more.  It  appears  to  be  made  as  claimed  from 
wheaten  flour  and  to  be  mainly  composed  of  torrefied  starch. 

For  an  infant  six  months  of  age  it  is  to  be  prepared  by  cooking  3  V, 
teaspoonfuls  of  food  in  21  ounces  of  water  and  20  ounces  of  milk. 

Composition  when  prepared  as  above: — 

Table  No.  44. 

Imperial  Granum.*  Woman's  Milk. 

Water 91.53  88.51 

Salts  0.34  0.34 

Proteids 2.15  2.35 

Fat   1.54  2.41 

Btarch 1.22 

Maltose,  dextrin,  etc 0.58 

Milk-sugar 2.71  6.39 

Reaction  alkaline.  Reaction  alkaline. 

The  total  of  solids  contained  is  one-quarter  less  than  in  woman's  milk ; 
the  carbohydrates  are  nearly  one-third  less  than  the  amoiint  in  woman's 
milk  and  it  should  be  observed  that  1.23  per  cent.,  or  about  one-fourth  of 
them,  consist  of  starch;  there  is  only  a  slight  deficiency  in  the  amount  of 

*  According  to  Chittenden, 


200  INFANT  FEEDING. 

proteids,  but  a  considerable  deficiency  in  tlie  amount  of  fat.  By  usinj^-  more 
milk  or  milk  and  cream  and  less  water  than  above  employed  the  percentages 
of  fat,  ])rotcids,  and  soluble  carl)oliydrates  would  be  increased. 

Its  very  large  proportion  of  starch  forms  the  principal  olijeelion  to  this 
food. 

The  presence  of  unconverted  starch  causes  the  thick  condition  of  the 
mixture. 

Eskay's  Albumenized  Food.^ 

This  food  is  to  be  prepared  with  cows'  milk.  Its  makers  state,  in  rec- 
ommending their  product,  that  it  contains  the  more  easily  digested  cereals, 
combined  with  egg  albumin. 

Eskay's  albumenized  food  consists  largely  (about  SS  per  cent.)  of  car- 
bohydrates; the  soluble  carbohydrates,  mostly  milk  sugar,  are  about  50  per 
cent.,  and  the  insoluble  carbohydrates,  mostly  starch,  are  a  little  less  than 
40  per  cent.  On  account  of  this  proportion  of  starchy  matter  in  the  dry 
food,  it  may  be  termed  farinaceous.  The  makers,  however,  c^aim  that  in 
the  process  of  manufacture  the  starch  granules  are  almost  entirely  disin- 
tegrated, and  when  the  food  is  prepared  with  milk  according  to  directions 
the  percentage  is  said  to  be  not  over  1  Y2  to  ^  P^r  cent.  An  analysis  of  the 
dry  food  shows  that  it  contains  about  9  per  cent,  of  proteid  matter,  but 
when  prepared  according  to  the  six  months'  formula  it  analyzes  about  2.55 
per  cent. 

The  fats  as  well  as  the  proteids  are  almost  entirely  vegetable,  with  a 
small  percentage  of  each  derived  from  eggs.  Excepting  the  egg,  fat,  and 
albumin,  the  preparation  is  produced  from  wheat,  oats,  and  barley,  and  while 
no  proteolytic  ferments  are  used  in  its  manufacture,  the  insoluble  carbo- 
hydrates are  nevertheless  partially  converted  into  dextrin  by  a  special  process 
of  heating,  which  ruptures  the  starch  granules  and  converts  a  small  amount 
of  the  starch. 

The  egg  albumin  is  said  to  be  first  combined  with  sugar  of  milk  in 
such  a  thorough  manner  that  the  particles  are  finely  subdivided,  and  no 
firm,  hard  coagulum  can  therefore  take  place  in  the  stomach.  The  particles 
retain  their  identity,  and  do  not  coalesce;  so  that  in  the  finished  prepara- 
tion the  egg  albumin  is  suspended  throughout  the  whole  mixture  in  very 
fine  particles,  which  are  easily  digested,  because  the  gastric  juice  acts  by 
contact,  and,  the  smaller  the  particles,  the  greater  the  effect  of  the  gastric 
juice.  No  claims  are  made  by  the  manufacturers  for  its  solubility,  but  for 
its  ease  of  digestion  and  its  nutritive  value. 


*  The  chemical  analyses  of  Eskay's  food,  Mellin's  food,  cereal  milk,  and  malted 
milk  here  given  were  specially  made  for  me  by  Professor  Lafayette  B.  Mendel,  at  the 
Sheffield  Laboratory  of  Physiological  Chemistry,  Yale  University. 


ESKAY'S  FOOD.  201 

The  directions  for  preparing  it  for  an  infant  six  months  of  age  are  to 
take: — 

Eskay's  food 5  tablespoonfula 

Hot  water   1  pint 

Rich  cows'  milk   2  pints 

As  directed. 

Composition  wlieu  prepared  as  above: — 

Table  Ko.  45. 

Eskay's  Food.      Woman^s  MilJc 

Water    84.46  80.73 

Total   solids 15.54  13.26 

Fats    3.07  4.13 

Proteids   2.78  2  00 

Inorganic    salts 0.58  0.20 

Carbohydrates 9.11  6.93 

The  reaction  to  litmus  was  amphoteric. 

The  food  contains  a  noticeable  quantity  of  starch  which  is  in  the  form 
of  a  thin  paste  in  which  all  the  grains  are  ruptured  by  the  process  of  prepa- 
ration. The  boiling  was  carried  on  for  fifteen  minutes  in  the  sample  an- 
alyzed. 

Eich  milk  (4.85  per  cent,  of  fat)  was  used  as  specifically  directed. 

Mellin's  Food. 

Mellin's  food  is  a  malted  cereal.  This  food  is  stated  by  its  makers  to 
be  a  soluble  dry  extract  from  wheat  and  malt,  for  the  modification  of  fresh 
cows'  milk. 

The  carbohydrates  therein  are  in  the  form  of  dextrin  and  maltose,  and 
constitute  about  80  per  cent,  of  the  food;  the  proteids  amount  to  about 
10  per  cent,  and  are  derived  from  the  cereals.  Mellin's  food  is  almost  com- 
pletely soluble  in  water.  It  is  especially  noticeable  that  this  food  does  not 
contain  any  starch. 

The  directions  for  preparing  this  food  for  use  for  infants  six  months 
of  age  and  over  are  to  dissolve  2  heaping  tablespoonfuls  of  food  in  V^  pint 
of  hot  water  and  V4  pint  of  cows'  milk. 

Composition  when  prepared  as  above: — 

Table  No.  46. 

Mellin's  Food.       Woman's  Milk. 

Water    85.37  86.73 

Total  solids 14.63  13.28 

Fats    3.18  4.13 

Proteids   3.03  2.00 

Inorganic    salts 0.70  0.20 

Carbohydralca    7.74  6.93 


202 


INFANT  FEEDING. 


The  reaction  to  litmus  was  amphoteric.  The  food  gave  no  reaction  for 
starch.    Milk  having  4.35  per  cent,  of  fat  was  used  in  this  preparation. 

In  total  solids  this  food  differs  but  slightly  from  woman's  milk,  and  in 
the  various  constituents  its  similitude  to  woman's  milk  is  remarkably  close. 
Of  the  carbohydrates  the  maltose  and  dextrin  are  a  little  less  in  amount 
than  the  milk  sugar,  and  the  total  carbohydrates  (7.74  per  cent.)  are  greater 
than  the  amount  in  woman's  milk. 

The  manufacturers  of  Mellin's  food  present  many  formulas  for  pre- 
paring the  food  for  use  to  meet  various  indications.  The  following  for- 
mulas are  given  with  the  analyses  of  the  respective  milk  modifications : — 

Table  No.  47. 

FORMUi-ii:  AND   Analyses  for  Preparing   Mellin's   Food. 

For  Infants  About  Two  Months  Old, 

Water  93.40 

Salts 0.35 


Mellin's    food,    6    teaspoonfuls 

(level). 
Milk,  6  Va  fluidounoes. 
Water,  9  V,  fluidounces. 


Mellin's  food,  2  taLlespoonfuls  "| 

(heaping). 
Cream,  1  V»  tablespoonfuls.  |- 

Milk,  4  fluidounces. 
Water,  12  fluidounces. 


Gives  this 
composition : 


Low  Proteids. 


Gives  this 
composition: 


Proteids    1.69 

Fat 1.53 

Carbohydrates        (no 

starch)    3.03 


Water  91.50 

Salts 0.37 

Proteids 1.45 

Fat 2.50 

Carbohydrates        (no 

starch)    4.18 


High  Fat  and  Low  Proteids. 


Mellin's  food,  3  tablespoonfuls  " 

(heaping). 
Milk,  4  fluidounces. 
Cream,  2  tablespoonfuls. 
Water,  12  fluidounces. 


Gives  this 
composition : 


Water  89.36 

Salts 0.45 

Proteids    1.65 

Fat 3.00 

Carboliydrates       (no 
starch)    6.54 


Just's  Food. 

Maltose,  free    12.6  parts 

Maltose,  combined  with  dextrin  as  maltodextrin 15.5  parts 

Dextrin,  with  trace  soluble  starch 61.3  parts 

Albuminoids 1-1  parts 

Fat 1  pait 

Ash   9  part 

Water   5.3  parts 

Cellulose 2  part 

Indeterminable    (insoluble)    3.0  parts 


100.0  paita 


PEPTOGENIC  MILK  POWDER.  *      203 

This  sample  was  neutral  in  reaction;  the  sample  was  analyzed  June 
14,  1895;  was  slightly  acid,  which  suggests  that  the  process  of  manufac- 
ture has  been  changed  a  little.    The  food  has  no  diastasic  action. 

The  small  amount  of  allDuminoids,  light  color  of  the  food,  and  the  low 
degree  of  conversion,  particularly  of  the  last  sample  analyzed,  indicate  very 
conclusively  that  no  considerable  quantity  of  malt  or  any  entire  cereal  is 
used  in  its  manufacture.  It  is  not  hygroscopic — it  can  be  exposed  to  air 
for  quite  a  long  time  without  becoming  sticky. 

Upon  examination,  the  above  analysis  indicates  a  close  relation  of  Just's 
Food  to  commercial  glucose,  although  it  contains  no  dextrose. 

A  product  similar  to  Just's  might  be  obtained  from  the  glucose  process 
if  the  process  were  stopped  early  in  the  coiiversion  before  the  starch  was 
converted  to  glucose;  that  is,  when  the  conversion  of  the  starch  has  pro- 
gressed only  as  far  as  dextrin  and  maltose ;  or  it  might  be  possible,  during 
the  process  of  making  glucose,  to  draw  off  a  portion  in  the  earlier  stages 
of  the  process,  and  neutralize  and  clarify,  and  obtain  a  product  similar  to 
Just's  food. 

In  order  to  get  such  a  percentage,  as  is  given  in  the  analysis  of  dextrin 
and  maltose,  from  a  starch  material  by  the  action  of  malt  diastase,  it  would 
be  necessary  to  use  so  much  malt  that  the  amount  of  albuminoids  contained 
would  be  much  larger  than  is  shown  by  the  analysis,  and  the  product  would 
have  a  decided  malt  flavor  and  quite  a  marked  color,  and  these  Just's  food 
has  not. 

Peptogenic  Milk  Powdek. 

This  product  is  stated  by  its  makers  to  be  an  article  containing  milk 
sugar  and  a  digestive  ferment  capable  of  acting  on  casein,  offered  for  the 
preparation  of  an  artificial  infant  food.  McGill  states :  "It  is  not,  in  the 
strict  sense,  a  food.  Its  professed  object  is  so  to  change  the  composition 
of  cows'  milk  as  to  render  this  comparable  to  human  milk.  This  it  seeks 
to  do  by  introducing  milk  sugar  and  small  quantities  of  albuminoids."  Ac- 
cording to  McGill's  analysis,  it  is  comi^osed  almost  entirely  of  milk  sugar 
(96.60  per  cent.). 

The  following  analysis  is  by  Leeds,  and  is  taken  from  a  circular  of  the 
makers. 

Composition  of  "humanized  milk"  prepared  as  directed,  using  4  meas- 
ures of  peptogenic  milk  powder  with  ^/^  pint  of  milk,  y^  pint  of  water, 
and  4  tablespoonfuls  of  cream : — 

Table  No.  48. 

Humanized  Milk.       Wowan's  Milk. 

Water    80.20  88.51 

Ash    0.30  0.34 

Proteids    2.00  2.35 

Fat    4.50  2.41 

Milk-sugar    7.00  6.39 

Reaction  alkaline.      Reaction  alkaline. 


204 


INFANT  FEEDING. 


Chittenden's  analysis  of  this  "humanized  milli"  is  ahnost  identical  with 
the  above. 

The  proteids  of  the  cows'  milk  undergo  a  change  in  the  peptonizing 
process,  being  converted  chiefly  into  partial  peptones,  and  in  this  form  they 
cannot  be  said  to  resemble  the  proteids  of  woman's  milk,  which  have  not 
been  acted  upon  by  a  proteolytic  ferment. 

Table  No.  49. — Summary  Giving  Comparison  of  the  Foods  Analyzed  by  Professor  Mendel. 


Cereal  Milk. 

Malted  Milk. 

Mellin'8  Milk. 

Eskay's  Milk. 

Human  Milk. 

Water       

Total  solids  .... 

90.98 
9.02 

90.74 
9.26 

85.37 
14.63 

84.86 
15.54 

86.73 
13.26 

Fats       

Proteids        ... 
Inorjianic  salts    . 
Carbohydrates     . 

0.38 
1.09 
0.21 
7.84 

0.63 
1.65 
0.36 
6.62 

3.16 
3.03 
0.70 
7.74 

3.07 
2.78 
0.58 
9.11 

4.13 
2.00 
0.20 
6.93 

Reaction  to  litmus 

neutral 

alkaline 

amphoteric 

amphoteric 

(The  figures  indicate  percentages  by  weight.) 


The  figures  quoted  for  human  milk  are  well-known  averages;   it  would 
be  more  accurate  to  give  figures  indicating  the  healthy  variations. 


Table  No.  50. 

Composition  of  some  Infant  Foods  as  Prepared  for  the  Nursing  Bottle  in  Comparison  with 
3Iother^s  Blilk.     Prepared  According  to  Directions  for  Infants  of  Six  dlonths.^ 


Special  Gravity 

Water  .        .  .    .   .    . 

Total  solid  matter    .    .    . 

Inorganic  salts      .    . 

Total  albuminoids    .    . 

Soluble  albuminoids    . 

Insoluble  albuminoids 

Fat  

Milk  sugar 

Cane  sugar 

Maltose       

Dextrin 

Soluble  Starch  .    .   .    . 

Starch 

Keaction      


Mother's 

Malted 

Milk. 

Milk. 

1031 

1025 

86.73 

92.47 

13.26 

7.43 

0.20 

0.29 

2.00 

1.15 

2.00 

1.15 

0 

trace 

4.13 

0.68 

6.93 

1.18 

0 

0 

0 

3.28 

0 

0.92 

0 

0 

0 

0 

alkaline 

alkaline 

Nestle's 
Milk  Food. 


1024 
92.76 
7.24 
0.13 
0.81 
0.36 
0.45 
0.36 
0.84 
2.57 
trace 
0.44 

1.99 

alkaline 


Imperial 
Grauum. 


1025 
91.53 
8.47 
0.34 
2.15 
1.67 
0.48 
1.54 
2.71 
0 
trace 
0.58 

1.22 
alkaline 


Mellin's 
Food. 


1031 

88.00 

12.00 

0.47 

2.63 

2.62 

0 

2.89 

3,25 

0 

2.20 

0.53 

0 

0 

alkaline 


Peptogenic 

Milk 

Powder. 


1032 

80.03 

13.97 

0.26 

2.09 

2.09 

0 

4.38 

7.26 

0 

0 

0 

0 

0 

alkaline 


•Copied  from  an  article  in  the  New  York  Medical  Journal,  July  18,  1896,  by  K.  H.  Chittenden,  Ph.  D. 


CHAPTER  VII. 

CONCENTRATED  PREPARATIONS  OF  ALBmnN. 
Among  the  concentrated  preparations  of  albumin  on  the  market  are : — 

SOMATOSE. 

Somatose,  meat  albumin,  isolated  artificially  by  chemical  process.  A 
remedy  which  has  more  the  character  of  a  pharmaceutical  preparation  of 
a  stimulant  tonic,  rather  than  of  a  food.  This  is  evident  also  in  its  cost. 
It  is  used  extensively  and  with  good  results.  It  is  advisable  to  be  cautious 
with  the  same  owing  to  the  diarrhoeal  tendency.  It  should,  therefore,  not 
be  given  to  very  young  infants. 

Chemical  analysis: — 

Water   11.41  parts 

Digestible  albumin   41.21  parts 

Peptone    27.12  parts 

Other  nitrogenous  substances  estimated  by  difference 
and  assumed  to  consist  of  meat  basis  and  ex- 
tractives     14.51  parts 

Ash    5.75  paits 

100.00  pai-ts 

Somatose  is  stated  to  be  prepared  from  meat.  It  is  a  light  yellow  pow- 
der, odorless,  nearly  tasteless,  and  readily  and  completely  soluble  in  water. 
The  solution  has  a  slightly  alkaline  reaction. 

The  substance  is  a  predigested,  nitrogenous  food. 

It  is  probably  made  from  animal  substances,  but  we  are  unable  to 
state  from  what  materials  or  by  what  process  the  article  is  manufactured. 
Its  content  of  phosphoric  acid  and  potassium  is  very  much  less  than  should 
be  the  case  if  it  were  prepared  from  muscular  tissue,  or  meat  in  the  usual 
sense  of  the  term. 

EUCASIN. 

Eucasin  is  an  ammoniated  salt  of  casein.  A  soluble  preparation  of 
casein,  obtained  by  chemical  process.  It  contains  phosphorus,  0.8  and  13.1 
per  cent,  of  nitrogen.  It  is  well  tolerated  by  older  children,  but  does  not 
prove  very  satisfactory  in  very  young  infants. 

NUTROL. 

Nutrol  is  the  sodium  compound  of  casein,  also  soluble. 

(205) 


206  •  INFANT  FEEDING. 


Tropon. 

Tropon  is  a  mixture  of  animal  and  vegetable  albumin.  Obtained  chiefly 
from  buckwheat  flour  by  dissolving  with  dilute  caustic  soda,  precipitating 
with  acid,  and  purifying  with  hydrogen  peroxide.  It  was  introduced  by 
Finkler  (Berlin  klin.  Woclien.,  1897,  Nos.  30,  33).  Also  sano-tropon, 
which  is  really  a  mixture  of  dextrinized  barley  flour  with  tropon.  Sana- 
togen  is  very  similar  to  the  latter  preparation,  and  consists  of  casein  with 
glycero-phosphate  of  sodium,  and  13  per  cent,  nitrogen. 

Plasmon. 

Plasmon  is  a  preparation  of  casein,  partly  soluble.  Obtained  by  chem- 
ical process,  the  use  of  carbonic  acid  and  bicarbonate  of  soda.  It  is  adapted 
for  the  strengthening  of  ordinary  broths,  but  it  must  be  distinctly  remem- 
bered that  all  of  these  preparations  are  merely  suggestions  as  "substitutes,'' 
and  should  never  be  thought  of  as  suitable  for  constant  feeding. 

SosoN. 

Soson  is  a  new  albuminous  product  resembling  plasmon  and  tropon 
in  nutritive  qualities. 

Other  foods  are  Sanose-Albumose  (Schering);  also  Sanatogen,  Eu- 
laciol,  Protogen  (Blum),  and  the  Somatose  Cream  Mixture  of  the  Elher- 
feld  Farhenwerlce. 

All  of  the  above  preparations  have  been  used  by  the  author  in  doses  of 
V2  teaspoonful  added  to  either  barley  soup,  chicken  broth,  farina,  or  rice 
gruel. 

When  typhoid  fever  and  such  disorders  tax  the  ability  of  the  attend- 
ing physician,  owing  to  the  rejection  of  food,  then,  and  then  only,  should 
milk  or  its  dilution  be  laid  aside  and  the  above  foods  given  a  trial.  Valu- 
able service  has  been  frequently  given  by  such  standard  preparations  as 
panopepton,  liquid  peptonoids,  and  Mosquera's  beef  Jelly,  where  the  gastric 
irritability   prevents  the  regular   administration   of   milk. 

Mosquera's  Beef  Meal. 

This  is  a  partially  digested  beef  preparation,  containing  in  addition 
to  the  proteids,  13.06  per  cent,  of  fat. 
The  analysis  is : — 

Water  6.68 

Salts  and  inorganic  substances 4.20 

Fats    13.06 

Insoluble  proteids  47.61 

Albumose    29.43 


ALBUMINOUS  FOODS.  207 

Taking  the  insoluble  proteids,  albumose  and  fats,  together,  100  grams 
are  equal  to  435  calories,  while  the  albumose  alone  represents  122  calories. 

Mosquera's  Beef  Jelly. 

This  beef  jelly  contains  12.66  per  cent,  of  albumose  and  14.35  per  cent, 
meat  extractives.  It  represents  therefore  the  stimulant  as  well  as  the  nu- 
trient qualities  of  beef. 

A  two-ounce  jar  is  equal  to  34  calories  from  the  albumose,  and  if  we 
were  to  take  the  meat  extractives  at  the  same  ratio,  the  total  number  of 
calories  would  be  94.  '  ' 

Panopepton. 

Panopepton  represents  the  products  of  the  peptic  digestion  of  fresh, 
lean  beef,  and  of  the  proteolytic  and  amylolytic  digestion  of  whole  wheat; 
proteids  in  the  form  of  albumose  and  peptone,  carbohydrates  as  achroo- 
dextrins  and  maltose,  and  the  natively  associated  soluble,  savory,  and 
stimulant  mineral  constituents.  These  soluble  food  constituents  are  ster- 
ilized, concentrated,  and,  after  being  duly  proportioned,  are  redissolved  in 
sherry  wine. 

Panopepton  contains  20  per  cent,  of  solids  as  follows: — • 

Soluble  proteids 6  per  cent. 

Carbohydrates    13  per  cent. 

Ash    , 1  per  cent. 

It  will  be  noted  that  the  ratio  of  proteids  and  carbohydrates  is  as  1  to 
2.16,  which  is  best  calculated  for  a  proper  nutritive  balance.  Harrington's 
analysis  shows  that  it  yields  17.99  per  cent,  of  solid  matter  (including  0.97 
per  cent,  of  mineral  matter)  and  18.95  per  cent,  by  volume  of  alcohol. 

This  is  undoubtedly  one  of  the  best  predigested  foods  of  the  class  that 
contains  both  proteids  and  carbohydrates  in  their  most  available  forms,  and, 
from  the  data  supplied  by  its  manufacturers,  it  is  evident  that  it  is  designed 
upon  scientific  principles  to  represent  the  varied  constituents  of  a  mixed 
diet,  and  that  its  preparation  is  carried  out  in  a  most  perfect  manner  in  all 
respects.  The  wine  serves  both  as  a  stimulant  and  preservative,  and  the 
product  has  an  agreeable  taste  and  flavor.  One  hundred  grams  (about  3  ^/g 
ounces)  equal  77.5  calories. 

It  must  not  be  taken  for  granted  that  because  one  chemist  finds  a  very 
high  percentage  of  alcohol  in  a  standard  preparation  that  the  same  amount 
will  be  found  by  other  chemists;  for  instance,  the  preparation  of  "liquid 
peptonoids,"  made  by  the  Arlington  Chemical  Co.,  was  sent  to  Dr.  Ernst  J. 
Lederle.    This  chemist  found  17.59  per  cent,  alcohol  by  volume. 


208  INFANT  FEEDING. 

Tabt.e  No.  51. — Chemical  Analijftes  by  Dr.  Erni^t  J.  Jjcderle  and 
J.  A.  DcgJmee,  Ph.D. 

An  interesting  coiiipanson  as  to  the  alcohol  content  can  be  made  by  studying 
the  analyses  of  the  six  nutritive  tonics  submitted  for  examination;    they  are: — ■ 

Nutritive   Liquid    Peptone 23.49  per  cent,  alcohol  by  volume 

(Parke,  Davis  &  Co.) 
Liquid  Peptonoids  17.59  per  cent,  alcohol  by  volume 

(Arlington  Chemical  Co.) 
Mulford's  Pre-Digested  Beef   ...   19.39  per  cent,  alcohol  by  volume 

(H.  K.  Mulford  &  Co.) 
Tonic    Beef    17.04  per  cent,  alcohol  by  volume 

(Shai-p  &  Dohme) 
Troplionine    18.98  per  cent,  alcohol  by  volume 

(Reed  &  Canirick) 
Panopepton    20.05  per  cent,  alcohol  by  volume 

(Faircliild  Bros.  &  Foster) 


CHAPTER  VIII. 
ADDITIONAL  NUTKIENTS  AND   STIMULANTS. 

Meigs's  Food. 

Meigs's  food  consists  of  milk,  cream,  sugar,  gelatine,  and  arrowroot, 
and  is  prepared  as  follows :  Of  Russian  gelatine  or  isinglass,  20  grains,  or  a 
piece  about  two  inches  square,  is  soaked  for  a  few  minutes  in  cold  water, 
and  then  boiled  in  half  a  pint  of  water  for  fifteen  minutes,  or  until  com- 
pletely dissolved.  One  teaspoonful  of  arrowroot  is  mixed  to  a  paste  with 
cold  water,  and  then  added  to  water  to  make  half  a  pint.  This  is  now  added 
to  the  gelatine  solution,  as  is  also,  with  constant  stirring,  the  desired  quan- 
tity of  milk;  Just  before  removing  from  the  fire  the  cream  is  added.  The 
amount  of  milk  and  cream  used  should  vary  with  the  age  of  the  infant. 
For  an  infant  under  one  month,  4  ounces  of  milk  and  1  ^/j  ounces  of  cream 
are  to  be  used ;  for  those  older  the  milk  is  gradually  increased  to  16  ounces 
and  the  cream  to  2  ounces.^ 

ZOOLAK. 

The  subjoined  analysis  of  Dr.  Dadirrian's  zoolak  was  made  by  Edgar 
E.  Wright,  of  Brooklyn,  N.  Y. 

In  every  100  parts  of  zoolak  there  are: — 

Water 87.G9 

Proteid   substances   3.98 

Fat    4.91 

Iklilk-sugar    2.U3 

Alcohol   0.07 

Ash  or  mineral  salts 0.78 

Lactic  acid 0.50 

Carbon  dioxide   0.0-1 

This  analysis  shows  that  in  the  production  of  zoolak  but  little  change 
i~  wrouglit  in  the  percentage  composition  of  the  original  cows'  milk,  save 
vlint  would  naturally  he  produced  by  the  fermenting  and  peptonizing  actions 
of  tlie  kefir  ferment. 

These  fermentative  changes — primary  and  secondary — consist  in  : — 

1.  Tlie  transmutation  of  a  portion  of  tlie  natural  milk  sugar  into 
alcohol,  lactic  acid,  and  carbon  dio.xide. 

2.  The  transmutation  of  a  certain  percentage  of  the  proteid  sub- 
stances into  protoses,  and  finally,  perhaps,   into  true  diil'usible  pej)ton('S. 


^  Meigs  and  Pepper:    "Diseases  of  Cliildren,"  1887. 

"  (20!)) 


210  INFANT  FEEDING. 

This  latter  action,  however,  does  not  change  the  percentage  presence  of  the 
proteid  bodies,  as  related  to  the  total  quantity  of  milk,  but  simply  changes 
their  chemical  form. 

Jurock's  kefir-ferment-pastilles  recently  introduced  in  our  country^  are 
a  very  rapid  and  practical  method  of  making  kumyss.  These  tablets  will 
keep  indefinitely  and  can  therefore  be  utilized  wherever  fresh  milk  can  be 
obtained.  Its  nutritive  value  has  been  well  established,  in  adults  as  well 
as  children. 

The  Nutritive  Value  of  Eggs. 

It  is  commonly  asserted  that  an  egg  contains  as  much  food  value  as  a 
half  pound  of  meat.  This  is  not  true.  While  there  is  an  approximate 
equivalent  between  the  albuminoids  contained  in  both,  the  egg  contains  no 
carbohydrates.  Very  young  infants  do  not  digest  eggs,  and  frequently  gas- 
tric disturbances  result  from  their  use.  This  does  not  necessarily  imply 
that  the  white  of  egg  in  its  raw  state  should  never  be  used  as  an  adjunct  to 
other  forms  of  feeding,  or  as  a  temporary  food  when  milk  disagrees  or  when 
diarrhoeal  conditions,  such  as  fermentative  and  catarrhal  intestinal  dis- 
eases, prohibit  the  use  of  milk. 

Lecithin. 

Lecithin  is  a  crystallizable  fat  of  a  peculiar  nature  containing  nitrogen 
and  phosphorus.  It  is  unstable.  When  chemically  treated  by  neurin  and 
glycerine  phosphoric  acid  can  be  isolated.  Lecithin  has  also  been  found  in 
the  yolk  of  egg,  in  the  eggs  of  fish,  etc.  Hoppe-Seyler  isolated  this  sub- 
stance in  1870  from  its  constant  association  with  phosphorized  albumins, 
nucleo-albumin,  and  nucleo-proteid.  Lecithin  is  also  found  in  the  brain 
matter. 

Free  lecithin  has  been  used  clinically  and  physiologically  by  Danilewski 
in  1895.  According  to  this  physiologist  animals  fed  with  lecithin  grew 
more  rapidly  than  those  not  fed  on  this  substance.  It  is  a  reconstructive 
and  is  indicated  in  the  treatment  of  all  disorders  of  nutrition.  My  experi- 
ence with  lecithin  has  been  limited  to  rachitis,  tuberculosis,  and  cases  in 
which  atrophy  due  to  malnutrition  is  found,  such  as  result  from  pertussis. 
I  am  also  using  it  in  cases  of  sporadic  cretinism. 

A  preparation  of  lecithin  containing  one  grain  of  pure  lecithin  to  the 
drachm  is  made  by  Fairchild  Bros.  &  Foster,  of  New  York  City.  A  tea- 
spoonfui  of  this  solution  given  three  times  a  day  before  meals  has  given  me 
very  good  results. 

Lecithin  of  the  Egg. — According  to  Coloumbe,  lecithin  exists  in  all 
the  tissues,  especially  in  those  endowed  with  great  vitality.  From  a  thera- 
peutic point  of  view  it  is  not  toxic,  and  it  is  assimilated  as  a  whole  in 
ordinary  doses.    Its  action  consists  in  increasing  the  number  of  red  cor- 


'  By  Dr.  L.  Amater. 


COCOA. 


211 


piiscles;  in  increasing,  in  certain  cases  at  least,  hasmoglobin ;  in  increasing 
urea  and  climinishiDg  nric  acid ;  and  in  stimulating  the  appetite.  Its  em- 
ployment is  indicated  in  anaemia,  in  all  troubles  of  nutrition,  in  wasting  dis- 
eases, and  in  neurasthenia.  It  inay  be  administered  hypodermically  or  by 
the  mouth. 

Steak  Juice  or  Meat  Juice. 

The  juice  of  broiled  steak  possesses  anti-scorbutic  properties.  I  have 
referred  to  this  in  the  chapter  on  scurvy.  When  dentition  is  delayed  or 
when  the  bony  structure  is  weak,  as  in  rickets,  steak  juice  should  be  freely 
given.  It  is  best  prepared  fresh  each  day.  For  this  purpose  a  meat  press 
(see  illustration)  is  convenient.  When  fresh  steak  juice  cannot  be  obtained, 
tben  Valentine's  meat  juice  can  be  tried.  For  the  treatment  of  scurvy  fresh 
meat  juice  must  be  used. 


¥is-  53. 


The  Use  of  Cocoa  in  Ciiilduen'. 

The  value  of  cocoa  as  an  infant  food  is  underestimated,  although  a 
great  many  preparations  of  cocoa  on  the  market  are  useless. 

Indications. — When  there  is  a  tendency  to  diarrhoea  and  in  general 
marasmic  conditions,  the  nutritious  effect  of  cocoa  should  be  remembered. 
I  frequently  add  one  or  two  teaspoonfuls  of  cocoa  to  modify  the  curd  in 
milk  in  the  same  manner  as  I  prescribe  some  of  the  infant  foods.  During 
convalescence  following  the  acute  infectious  diseases,  especially  diphtheria 
and  scarlet  fever,  cocoa  should  be  given.  In  pulmonary  catarrh  and  in 
tuberculous  manifestations,  the  use  of  cocoa  is  indicated.  If  milk  is  not 
well  borne  I  frequently  add  one  or  two  teaspoons  of  cocoa  properly  sweet- 
ened to  rice  water. 

H.  Cohn,^  in  describing  the  chemical  value  of  cocoa  as  nourishment, 
states  his  belief  that  it  is  overrated,  and  denies  the  value  of  the  same.    He 


•  Zeitschrift  fiir  physioiogiselie  Clicmio,  xx,  1,  2. 


212  INFANT  FEEDING. 

bases  his  statement  on  the  poor  method  of  assimilation,  owing  to  the  large 
quantity  of  fat  which  could  be  removed  by  chemical  process.  Cocoa  also 
contains  5.5  per  cent,  of  tannic  acid.  Besides,  the  albuminoids  are  con- 
verted, by  the  process  of  roasting,  into  a  very  indigestible  product.  About 
the  tannic  acid,  he  says  that  it  precipitates  the  digestive  ferments,  and  unites 
with  the  albuminoids  into  insoluble  compounds,  causing  the  constipating 
factor.  According  to  his  experiments,  only  one-half  of  the  16.6  per  cent, 
of  the  albuminoids  are  absorbed,  and,  in  order  to  give  the  human  body 
enough  cocoa  to  have  a  sufficient  quantity  of  proteids,  it  would  be  neces- 
sary to  feed  at  least  somewhat  over  2  pounds  daily,  provided  cocoa  alone 
was  given  for  nourishment. 

A  cocoa  is  found  on  the  market  in  which  a  large  percentage  of  oil  has 
been  extracted.     This  renders  it  more  easily  digested.^ 

Chocolate. 

Chocolate  contains  about  45  per  cent,  of  cane  sugar,  but  no  dextrose 
or  Iffivulose.  The  remainder  consists  of  cocoa  powder.  Invert  sugar,  or  a 
mixture  of  glucose  and  albumin,  is  largely  used  in  the  preparation  of  un- 
crystallized  sweets,  such  as  the  creamy  matter  in  the  interior  of  chocolate 
drops.  The  coloring  of  sweets  is  derived  either  from  burnt  sugar  or  from 
one  of  the  aniline  dyes,  most  commonly  eosin.  Cochineal  is  also  a  favorite 
colorer.  It  is  interesting  to  know  that  these  dyes  may  be  excreted  in  the 
urine  almost  unchanged,  and  cases  are  on  record  where  patients  were  sup- 
posed to  be  passing  blood  when  they  had  merely  been  sucking  red  sweets. 
There  is  no  reason  to  suppose,  however,  that  such  substances  are  harmful 
to  life.^  When  there  is  a  tendency  to  loose  bowels,  especially  after  the 
second  summer,  cocoa  and  chocolate  should  be  added  to  the  dietary.  It  is 
to  be  added  to  milk  and  thoroughly  boiled.  One  cocoa  feeding  per  day  is 
usually  enough.  One  teaspoonful  of  cocoa  to  a  cup  of  milk,  the  latter  to 
be  thoroughly  boiled,  is  the  usual  quantity  used.  Several  formulae  for 
making  chocolate  will  be  found  in  the  "Dietary." 

Ice-cream  and  Water-ices. 

Ice-cream  and  water-ices  are  very  grateful  to  a  feverish  child.  When 
milk  and  cream  are  refused  they  will  be  greedily  taken.  These  prepara- 
tions will  alleviate  the  pain  on  swallowing  in  the  case  of  diphtheria.  They 
contain  considerable  nourishment,  but  must  be  given  in  moderation.  Nau- 
sea and  vomiting  may  frequently  be  controlled  by  them. 


*This  cocoa  is  manufactured  by  Croft  &  Allen,  of  Philadelphia.     It  is  put  up 
In  glass  jars. 

'  Hutchison,  "Food  and  Dietetics,"  page  2Go. 


COFFEE.  213 


The  Use  of  Coffee  in  Children.* 

Contraindications. — When  giving  coffee  to  children  we  must  bear  in 
mind  that : — 

First. — Coffee  is  in  no  sense  a  food,  because  it  can  neither  build  up 
the  tissues  nor  provide  them  with  potential  energy. 

Second. — Coffee  perliaps  acts  the  part  of  a  lubricant  to  the  machinery 
of  the  body,  and  exerts  its  stimulating  influence  by  touing  up  and  dimin- 
ishing nervous  fatigue   in  adults,  and  is  not  called  for  in  children. 

Third. — Coffee  produces  a  disturbance  of  digestion  due  to  a  direct 
interference  with  the  chemical  part  of  the  process,  but  in  part  also  indi- 
rectly brought  about  by  the  nervous  system;  it  also  produces  a  dyspepsia 
which  is  of  the  atonic  type,  and  a  slow  digestion,  accompanied  by  flatu- 
lence, with  a  disturbance  of  the  heart's  action,  so  that  it  is  decidedly  con- 
traindicated  from  a  feeding  standpoint. 

Coffee  is  a  cardiac  stimulant,  quickening  the  heart's  action  in  small 
doses,  and  depressing  it  in  large  quantities. 

It  certainly  disturbs  the  cardiac  rhythm  when  taken  in  excessive  doses 
by  children.  Such  symptoms  are  muscular  tremor,  nervous  anxiety,  and 
dread  of  impending  danger,  as  well  as  palpitation;  cardiac  intermissions, 
and  an  uncomfortable  feeling  referred  to  the  cardiac  region  can  be  traced 
to  coffee,  according  to  Yeo;  it  is  a  diuretic,  and  increases  the  excretion  of 
urea;  it  produces  insomnia,  nervousness,  and  fear;  also,  choreiform  move- 
ments. 

Caffeine  has  been  known  to  produce  paralysis  in  the  lower  animals, 
and  might  produce  a  similar  effect  if  taken  in  large  quantities  by  children. 
It  retards  digestion,  hence  it  is  contraindicated  in  children. 

Owing  to  the  great  tendency  to  produce  insomnia  coffee  should  not  be 
administered  in  the  evening  unless  the  heart's  action  demands  it. 

Indications. — As  a  cardiac  stimulant,  or  whenever  caffeine  is  indicated, 
hot  coffee  should  be  given  in  small  doses,  one  or  several  teaspoonfuls.  re- 
peated every  fifteen  minute?,  until  its  physiological  effect  is  manifested. 
'J'his  can  only  be  noted  by  studying  tlie  pulse.  Great  care  should  be  exer- 
cised in  administering  large  quantities  of  coffee  to  children,  or  very  strong 
cofl'ce,  as  in  either  instance  it  will  produce  a  marked  cardiac  depression, 
and  also  a  disturbance  of  the  cardiac  rhythm. 

In  the  convalescence  of  typhoid  fever  or  pneumonia  in  children,  there 
is  no  better  stimulant  than  coffee  admin'stered  in  small  doses  to  which 
large  quantities  of  mi'k  or  cream  are  added.  This  is  an  especially  valuable 
dose  in  the  great  cardiac  depression  so  frequently  noted  in  the  convales- 

'  Paper  read  by  me  before  New  York  County  Medical  Association,  December  17, 
1900,  "Acute  and  Chronic  Cotl'ee  Poisoning."     See  Transactions. 


214  INFANT  FEEDING. 

cence  of  diphtheria.     (See  chapter  on  "Diphtheria.")     The  coffee  usually 
used  consists  of  the  following  strength: — 

Coffee 2  ounces 

Water    1  pint 

When  an  infusion  of  the  above  strength  is  made,  Hutchison  found 
that  each  teacupful   of   coffee   contained : — 

Caffeine   1.7     grains ;    and  also 

Tannic  acid   3.24  grains 

The  latter  in  the  form  of  gallo-tannic  acid;  so  that  judging  from  this 
analysis,  coffee  should  be  made  much  weaker  (one  ounce  to  a  pint  of  water), 
and  should  bo  administered   in   teaspoonful   doses. 

For  fuller  details  on  "Physiological  Effect  of  Coffee/'  read  paper  and 
discussion  at  the  New  York  County  Medical  Association,  1900,  by  Leszyu- 
sky,  Fischer,  and  others. 

The  Use  of  Alcohol  in  Children. 

Alcoliol  in  the  form  of  wine  or  beer  or  whisky,  in  any  and  every  form, 
is  not  only  detrimental  to  the  infantile  organism,  but  will  leave  permanent 
injury  if  its  use  is  prolonged.  There  is  a  decided  difference  between  tlie 
continual  use  of  alcohol  as  a  food  and  its  use  when  indicated  as  a  medicine. 
I'hysicians  know  that  whisky  or  wine  given  to  stimulate  the  weakened  heart 
in  the  course  of  a  fatal  attack  of  jmcumonia  or  diphtheria,  is  not  only 
necessary,  but  frequently  the  only  means  of  prolonging  life.  It  can  easily 
be  seen  that  if  a  child  has  been  brought  up  and  given  alcoholic  drinks  daily 
as  an  adjuvant  to  the  other  articles  of  food,  that  in  such  critical  times 
when  required  to  stimulate  the  heart  we  must  either  resort  to  enormous 
doses  to  procure  a  given  effect  or  many  times  we  will  fail  in  producing 
a  certain  effect  which  may  mean  the  loss  of  a  precious  life.  Thus,  it  be- 
comes necessary  to  emphasize  the  importance  of  abstaining  from  habitual 
feeding  of  alcoholic  drinks  in  any  form  to  the  young  and  growing  child. 

In  a  large  children's  clinic  with  which  I  have  been  associated  it  was 
very  interesting  to  study  the  amount  of  alcohol  given  to  young  children, 
and  I  was  surprised  to  find  that  more  than  50  per  cent,  of  all  children  from 
six  months  old  and  upward  regularly  received  their  sip  of  \)vrv  oi-  drop  of 
whisky  "to  strengthen  their  hearts."  The  author  has  frequently  attended 
alcoliolic  dyspepsia  due  to  prolonged  use  of  beer  and  wine.  This  is  most 
common  among  the  tenement  population,  where  llie  l)ahy  forms  part  of  the 
family  at  the  table,  and  necessarily  partakes  of  almost  everything  eatable 
and  drinkable  along  with  its  parents. 


TEA.  215 

The  Use  of  Tea  in  Children. 

In  my  chapter  on  the  use  of  coffee,  I  have  already  mentioned  the 
deleterious  effect  of  coffee  on  the  growing  infant  or  child;  what  has  been 
said  there  regarding  coffee  applies  equally  strong  to  the  use  of  tea.  The 
nervous  system  when  overstimulated  in  an  infant  is  far  more  sensitive  than 
the  adult.  The  author  has  frequently  noted  that  children  suffered  with 
sleeplessness  and  were  very  irritable,  simply  through  the  prolonged  use  of 
such  stimulants  as  tea  and  coffee.  A  noteworthy  point  is  that  the  appetite 
disappears  when  tea  and  coffee  are  given,  and  reappears  when  their  use  is 
interdicted. 

It  must  not  be  supposed  that  tea  is  a  poison,  and  there  are  times  when 
physicians  will  find  it  necessary  to  use  small  quantities  of  tea  to  stimulate 
the  body,  as  for  example,  in  that  form  of  exhaustion  following  a  protracted 
diarrhoea,  as  is  usually  the  case  in  summer  complaint,  so-called  cholera 
infantum. 


CHAPTER  IX. 

INFANTS'  WEIGHT. 

"When  a  child  develops  normally,  it  gaics  in  weight.  Breast-fed 
infants,  as  a  rule,  gain  more  than  bottle-fed  infants.  The  progress  of  an 
irifant  can  be  watched  by  a  comparison  with  its  weight.  The  moment  a 
child's  weight  is  stationary,  the  reason  for  the  same  should  be  ascertained. 


Fig.  54. — ^The  Chutillon  Scale  is  a  very  convenient  basket  scale.     It  is  very 

useful  in  the  nursery. 


If  the  baliy  is  breast-fed  the  milk  of  the  nursing  mother  sliould  be  sent  to 
a  chemist  for  examination.  (The  details  have  already  been  described  in 
the  chapter  on  "Breast-milk.'^) 

Disturbances  of  the  mother  interfering  with  proper  lactation  are  at 
once  evident  in  her  milk.  Such  disturbances  are:  (a)  menstruation,  (b) 
general  anaemia,  (c)  tuberculosis,  (d)  pregnancy  will  frequently  alter  the 
percentages  of  the  ingredients  of  milk  so  that  a  child  will  not  receive 
sufficient  nutrition. 

.(216), 


WEIGHT  IX  BREAST-FEEDING.  217 

The  first  evidence  of  such  malnutrition  Avill  be  scon  on  the  scales. 
The  child  will  not  gain  in  weight,  and  frequently  it  will  L.sc  weight. 

How  Much  Should  an  Infant  Weigh? — The  average  Aveight  at  birth 
is  7  pounds.  Some  children  weigh  considerably  more  and  some  less.  A 
child  should  double  its  weight  at  the  end  of  five  months,  and  treble  its 
weight  at  the  end  of  the  first  year.  It  must  not  be  supposed  that  because 
a  child  weighs  less  than  this  amount  that  it  may  not  be  healthy.  All  fac- 
tors should  be  taken  into  consideration  and  a  child  should  be  carefully 
examined  to  determine  whether  or  no  it  is  normal.  Very  many  babies  are 
up  to  the  normal  in  weight,  and  still  show  marked  rachitis.  The  very  fat 
and  flabby  baby — usually  supposed  to  be  extremely  healthy  by  the  laity — 
is  the  one  in  whom  physicians  most  frequently  meet  with  constitutional 
disorders.  Thus,  too  much  stress  should  not  be  put  on  the  scales,  for  we 
know  that  they  have  their  limitations.  In  the  beginning,  or  during  the  first 
and  second  months,  a  normal  infant  gains  about  6  to  8  ounces  a  week.  Dur- 
ing the  third  month  a  child  gains  from  i  to  6  ounces  per  week,  and  after  the 
third  month  from  3  to  4  ounces  per  week. 

Weighing  Immediately  After  Nursing  to  Determine  the  Quantity  of 
Milk  an  Infant  has  Taken.— "When  scanty  milk  supply  is  suspected  in  either 
the  nursing  mother  or  in  a  wet-nurse,  then  we  can,  in  some  instances,  resort 
to  weighing  immediately  after  the  baby  has  nursed.  It  is  understood  that 
the  child  must  be  weighed  both  immediately  before  nursing  and  then  imme- 
diately after  nursing.  The  difference  in  weight  is  the  amount  of  milk 
swallowed. 

While  this  may  serve  in  some  cases,  the  author  has  not  found  it  very 
practical,  and  cannot  recommend  it,  excepting  in  rare  instances. 

It  is  well  known  that  an  infant  whose  stomach  is  filled  requires  rest 
after  nursing,  and  the  less  it  is  handled  the  less  is  the  chance  for  expelling 
its  food.  Thus,  my  advice  is  not  to  handle  or  fumble  with  a  child  after 
nursing,  but  rather  aid  Nature  in  resting  an  infant  than  provoke  vomiting 
by  unnecessary  handling. 

Table  No.  52. 
Tabic  f^hovhifi  tlir  (lain  of  a  Healthy  Infant  Fed  at  the  Breast. 

Normal     weight    at    biilh,    7  Gain   at   tlie   end   of   the    first 

lb.  week,  none. 

Weight  when  2   weeks   okl,   7  Gain  at  the  end  of  2  weeks,  6 

lb.  6  oz.  oz. 

Weiglit   when  3   weeks   old,   7  Gain  at  the  end  of  3  weeks,  3 

lb.  14  oz.  oz. 

Weight  when  4  weeks   old,  8  Gain  at  the  end  of  4  weeks,  8 

lb.  6  oz.  oz. 


218 


INFANT  FEEDING. 


The  following  cases  will  serve  to  illustrate  the  weight  of  infants  with 
various  methods  of  feeding — (a)  breast-feeding,  (b)  home  modification, 
(c)  laboratory  feeding: — 


/9 


/8 


n 


lb 


16 

% 

^    li 

"fl    IZ 
a? 

II 


10 

9 

Birth  8 

7 


S!     IZ.     /f   zf    A-f    2f    ,?j?    .^^  __4o     ^ 


^ 


11 


I 


7. 


-.' 


7 


Fig.  55.      (Original.) 


Baby  Robert  M.  F.  Normal  at  birth.  Was  wet-nursed.  Gain,  first  month, 
2  V<  pounds;  second  month,  1  "/„  pounds;  third  month,  1  Vs  pounds;  fourth  month, 
1  Vg  pounds.  Stools  were  normal.  Had  gastric  disturbances  and.  symptoms  of 
colic  while  the  wet-nurso  menstruated.  When  the  child  was  about  seven  months 
old  the  chemical  analysis  of  the  breast-milk  showed  a  deficiency  of  fat  and  quite  a 
high  percentage  of  proteids.  The  milk  supply  gradually  gave  out  and  it  was 
necessary  to  wean  the  child. 


WEIGHT    FN   ARTIFICIAL    FEEDING. 


219 


^c^t  \^  yx>^€^'b 


ISJJ  '^  il''^  ''^^^  ^  ^  '^^^  ^^, 


Fig.  56.      (Original.) 

Baby  J.  S.  Bom  prematurely.  Weighed  5  pounds,  14  ounces  at  birth.  Was 
bottle-fed.  Vomited,  had  dyspeptic  symptoms,  such  as  cheesy  stools,  restlessness 
at  night,  crjung  continually,  and  excoriated  anus.  When  one  month  old  the  weight, 
including  shirt  and  diaper,  was  6  pounds.  A  wet-nurse  was  procured.  The  child 
gained  1  pound  during  the  first  week,  and  an  average  of  10  ounces  a  week  thereafter. 
Dyspeptic  symptoms  disappeared,  stools  became  normal.  The  child  was  not  seen  for 
bIx  months,  and  is  a  perfectly  healthy  baby  to-day. 


-   :s 

I 

,] 

4 

(S 

7 

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General   condition 


220 


INFANT  FEEDING. 


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Baby  A.  Case  of  chronic  dyspepsia,  Cliild  four  months  old,  weighed  8  pounds 
15  ounces.  Gainrd  13  ounces  the  first  week  of  treatment;  6  ounces  the  second  week; 
7,  12,  9  ounces  respectively  during  each  of  the  succeeding  weeks.  The  food  ordered, 
and  details  of  this  interesting  case  on  page  175. 


Vvo^t  \XV  \i>e.t\^s 


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Baby  D.  S.     Weighed  5  poujids  at  birth.     Was  fed  at  Walker-Gordon  Labora- 
tory since  six  weeks  old.     Lost  Mcight  during  an  attack  of  measles  when  twenty-six 


WEIGHT  IN  LABORATORY  FEEDING.  221 

weeks  old.     Did  not  gain  one  ounce  from  the  thirty-eighth  to  the  forty-second  week, 
although  received  a  formula  of:  — 

Fat   4.00 

Sugar   6.50 

Proteids 2.50 

Six  feedings,  of  seven  ounces  each. 

I  ordered  the  following  home  modification : — 

Raw  milk   6  ounces 

Barley  water   2  ounces 

Mellin's  food 2  teaspoonfuls 

Feed  every  three  hours. 

In  addition  thereto  1  ordered  one  ovmce  of  steak  juice  or  one  ounce  of 
orange  juice,  daily  one  hour  before  feeding. 

I  also  gave  the  white  of  one  raw  egg  with  the  evening  feeding.  The 
food  agreed  very  well  and  child  gained  in  weight  as  1  gradually  added  more 
milk  and  reduced  the  quantity  of  barley  water. 

A  growing  child  needs  far  more  food  than  its  weight  alone  would 
indicate,  for  its  income  must  exceed  its  expenditure  so  that  it  may  grow. 
An  infant  for  the  first  seven  months  or  first  one-half  j^ear  of  life  should 
have  nothing  Init  milk.  Up  to  this  age  vegetable,  food  is  unsuited  to  it; 
it  is  purely  a  carnivorous  animal. 

The  diet  of  the  infant  is  nearly  twice  as  rich  in  proteids,  half  as  rich 
again  in  fats,  and  a  little  more  than  half  as  rich  in  carbohydrates  as  that 
of  the  adult.    It  is,  therefore,  in  a  physiologic  sense  a  luxurious  diet. 

The  strain  of  growth  falls  heavier  u]ion  the  more  precious  proteids  than 
upon  the  more  cheap  and  common  carl:)ohydrates.^ 

When  children  do  not  gain  in  weight,  the  quantity  of  sugar  should 
be  increased.  Tliis  should  be  done  continuously  and  with  due  consideration 
for  tlie  other  ingredients. 

The  constructive  ingredient  in  an  infant's  food  is  the  proteids.  We 
must,  therefore,  consider  this  element  when  an  infant's  weight  is  stationary. 

Individual  conditions  must  be  considered,  and  chronic  disorders  elim- 
inated, e.g.,  dyspeptic  conditions  or  tuberculosis,  before  arriving  at  a  diag- 
nosis of  what  really  causes  an  infant's  loss  in  weight. 

'"Stewart's  Physiologj,"  p.  412,  1897. 


PART  IV. 

DISEASES    OF    THE    MOUTH,    (ESOPHAGUS,    STOMACH, 

IiNTESTINES,     AND     RECTUM,     AND     DISEASES 

ASSOCIATED  WITH  IMPROPER  NUTRITION. 


CHAPTER  I. 
DISEASES  OF  THE  MOUTH. 

Stomatitis. 

An  infection  existing  on  the  tonsils  or  in  the  pharynx  can  spread  to 
the  mouth.  Food,  especially  milk,  is  sometimes  the  means  of  directly  con- 
veying poison;  this  is  especially  true  when  milk  contains  pathogenic  bac- 
teria. As  I  have  frequently  stated  that  syphilis  and  rickets  undermine  the 
system,  so  also  we  find  these  conditions  frequently  as  predisposing  causes. 
The  mouth  is  particularly  liable  to  local  infection.  The  slightest  trauma- 
tism by  diseased  teeth,  especially  in  acute  cases,  can  produce  local  irritation. 
Non-pathogenic  bacteria  are  always  present  in  the  buccal  cavity  under  nor- 
mal conditions. 

"The  glands  of  the  mouth  being  excretory  frequently  produce  inflam- 
matory conditions  by  virtue  of  systemic  poison  excreted  by  them  which 
may  produce  local  lesions."  One  of  the  best  writers  on  this  subject  is 
Forchheimer,  whose  classification  I  have  adopted :  I.  Stomatitis  Catar- 
rhalis.  II.  Stomatitis  Aphthosa.  III.  Stomatitis  Mycosa.  IV.  Stomatitis 
Ulcerosa.  V.  Stomatitis  Gangrenosa.  VI.  Stomatitis  Crouposa;  Stoma- 
titis Diphtheritica.    VII.  Stomatitis  Syphilitica. 

Stomatitis  Catarrhalis. 

Simple  stomatitis  may  be  confined  to  a  local  area  or  it  may  be  general. 
When  the  mucous  membrane  is  irritated  by  severe  rubbing  as  during  mouth 
cleaning,  this  condition  frequently  follows.  Dentition  does  not  produce 
stomatitis.  This  catarrhal  form  is  usually  one  of  the  earliest  manifesta- 
tions of  acute  infectious  diseases.  Great  stress  is  laid  on  this  condition 
as  a  diagnostic  point  in  measles  prior  to  or  associated  with  the  enanthem 
on  the  buccal  mucous  membrane.  When  a  small  area  is  affected,  a  local 
cause,  such  as  a  diseased  or  sharp  tooth,  or  some  mechanical  cause,  must  be 
looked  for. 
(222) 


STOMATITIS  APHTHOSA.  223 

Symptoms. — The  usual  symptoms  of  pain,  hypergemia,  and  swelling 
are  noted.  The  lining  of  the  mouth  is  puffed  and  hyperffimic.  The  mucous 
membrane  is  covered  with  small  round  prominences  due  to  the  swelling  of 
the  muciparous  follicles.  When  the  ducts  of  the  latter  become  closed  the 
glands  dilate  and  there  are  produced  cysts,  the  contents  of  which  are  clear, 
viscid  mucus.  We  also  find  slight  epithelial  abrasions,  sometimes  leading 
to  the  production  of  a  deeper  process;  at  all  events  important  in  that  they 
may  become  the  seat  of  infection.  The  lymphatics  are  usually  involved, 
and  they  serve  as  a  guide  to  the  intensity  of  the  inflammation.  Cases  are 
on  record  where  the  temperature  reached  10-i°  F.  in  the  rectum,  but  these 
are  rarities. 

The  prognosis  is  invariably  good.  Unless  some  chronic  disease  is  the 
seat  of  this  trouble  there  are  rarely  any  disagreeable  after-effects. 

Treatment. — The  treatment  consists  in  cleanliness,  Remove  the  cause 
if  possible.  Eemove  mechanical  irritants,  such  as  diseased  or  sharp-pointed 
teeth.  Boric  acid,  1  per  cent,  solution,  or  sulphocarbolate  of  zinc  or  sulpho- 
carbolate  of  soda,  1  grain  to  the  ounce,  are  valuable  local  astringents.  At 
tim.es  nitrate  of  silver  (2  grains  to  the  ounce)  will  act  well  when  applied 
locally.  Forchheimer  recommends  the  application  of  silver  nitrate  when 
there  is  loss  of  epithelium.  Cysts  should  be  opened  and  their  walls  cau- 
terized when  necessary.  My  best  results  are  obtained  by  the  use  of  argyrol, 
5  to  10  per  cent,  solution. 

Stomatitis  Aphthosa. 

This  condition  is  not  follicular  and  has  nothing  to  do  with  the  muci- 
parous follicles,  as  it  is  found  in  places  where  there  are  none. 

It  consists  in  a  hypersemia  of  the  mucous  membrane  of  the  mouth 
associated  with  superficial  ulcers. 

Causes. — There  seems  to  be  a  decided  reason  for  believing  that  this 
disease  is  of  microbic  origin.  Aphthous  ulcerations  have  been  seen  in 
children  partaking  of  milk  from  cows  that  suffered  with  foot  and  mouth 
disease.  Demme^  reports  a  case  of  twins  fed  on  goat's  milk,  the  goat  having 
foot  and  mouth  disease.  The  milk  was  fed  fresh  and  raw.  One  of  the 
twins,  the  boy,  had  a  severe  aphthous  condition  of  the  entire  mouth  and 
throat,  and  died  after  seven  days  of  illness.  The  otlier,  a  girl,  was  also 
sick  with  aphthous  sore  mouth,  but  recovered  after  five  days'  illness. 

Robinson^  reports  a  severe  epidemic  of  aphthae  acquired  from  foot 
and  mouth  disease  in  Devonshire.  Two  hundred  and  five  persons  were 
affected  in  one  week.  Two  children  died,  the  aphthous  condition  having 
extended  to  the  respiratory  tract. 


•Vienna  Medical  Journal,  vol.  vi,  1883. 
*  London  Practitioner  for  1884. 


224 


DISEASES  OK  THE  ^ilOlTH. 


Boas,  of  Berlin,  has  also  rojKirtt'd  cases  of  foot  and  month  disease  and 
their  results.  Bohn  states  tliat  tlie  disease  is  most  common  between  ilic 
tenth  and  thirteenth  months  of  life.  Therefore^  teething  has  something  to 
do  with  the  eruption.  Siegel  studied  an  ejjidemic  of  foot  and  mouth  dis- 
ease, resulting  in  aphthous  stomatitis  in  children.  An  ovoid  bacillus  0..")  fx. 
long  was  found  in  all  cases.  We  can  assume  that  f(H)t  and  mouth  disease 
in  cattle  is  the  etiological  factor  of  stomatitis  aphthosa  in  the  human  being. 
Symptoms. — AA'liite  or  }X'llowish-white  epithelial  spots  are  seen  singly 
or  in  groups,  surrounded  by  an   areola  and  developing  anywhere  in  the 

mouth.  In  many  casos 
they  extend  into  the 
pharynx,  and  Forch- 
heimer  believes  into 
the  larynx.  This  dis- 
ease is  frequently  as- 
sociated with  acute 
gastric  catarrh,  consti- 
pation, and  with  gen- 
eral toxEemic  condi- 
tions. The  eruption 
may  be  preceded  by 
pain  in.  the  throat, 
fever,  enlargement  of 
the  lymphatics,  and  a 
general  train  of  nerv- 
ous symptoms  so  com- 
mon in  children. 

The  diagnosis, 
therefore,  will  be  diffi- 
cult until  the  erup- 
tion appears.  'V\\q. 
spots  frequently  are 
absoi'bed.     iSuccessive  crops  may  come  and  go. 

Treatment. — The  treatment  consists  in  giving  laxatives  such  as  rhu- 
barb and  magnesia,  or  inf.  senna  comp.  The  diet  must  l)e  regulated.  If 
the  child  has  been  given  solids  they  should  be  excluded.  The  discontin- 
uance of  milk  is  frequently  beneficial. 

Locally,  a  weak  solution  of  listerine  as  an  antiseptic  can  be  used.  If 
the  child  is  old  enough  it  should  rinse  its  mouth  and  gargle  its  throat  with 
the  same.  Nitrate  of  silver,  10  grains  to  the  ounce,  or  in  some  instances 
tincture  of  cliloride  of  iron,  has  served  me  very  well.  The  glycerite  of  car- 
bolic acid  aj)plied  with  al)Sorbeiit  cotton  is  fi'cquently  efTicacious. 


Fig.  59a. — A  Case  of  Sprue  (Thrush)  due  to  Faulty 
Hygiene  of  the  Mouth  Note  Threads  (Mycelium)  and 
Small  Oval  Bodies  (Spores).  (After  Jagic,  Kiinische  Mi-- 
kroskopie.) 


STOMATITIS  :\1YC0SA.  225 

Bedxar's  Aphtjf.t:. 

These  are  pcen  on  the  soft  palate.  They  may  be  mistaken  for  the 
ulcers  iiroduced  by  the  breaking  clown  of  milia  or  retention  cysts,  or  from 
that  condition  described  by  Epstein  in  which  there  are  congenital  defects 
in  the  mucous  membrane  filled  up  with  epithelial  detritus  (Forchheimer). 
They  are  always  the  result  of  violence  in  cleaning  the  mouth.  They  are 
benign  and  get  well  without  treatment.  Frequently  an  improperly-shaped 
nipple  will  cause  this  condition  by  pressing  on  the  palate.  Changing  the 
nipple  will  remove  the  cause. 

Dr.  A.  Jacobi,  in  the  Archives  of  Pediatrics,  says : — 
''Do  not  be  so  fearfully  clean.  Perhaps  it  is  best  to  leave  the  infant's 
mouth  alone  with  the  exception  of  the  first  Avashing  Avith  sterilized  water 
immediately  after  birth.  Otherwise  the  mouth  should  be  cleaned  by  the 
l)aby's  feeding  and  by  the  practice  I  have  recommended  these  dozen  of  years 
— viz. :  to  give  a  teaspoonful  or  two  of  water  after  every  feeding.  That  will 
wash  down  all  remnants  of  food  that  might  get  decomposed  in  the  mouth. 
These  'aphthge'  will  get  well  when  left  alone;  but  as  long  as  there  is  a 
sore  surface  there  is  a  possibility  of  microbic  invasion;  for, that  reason 
alone  they  should  be  treated.  Use  a  soft  brush  in  the  mouth  every  hour 
with  a  few  drops  of  chlorate  of  potassium  solution,  one  to  thirty,  or  milder, 
but  do  not  rub  or  be  rough." 

Stomatitis  Mtcosa,  or  Parasitic  Stomatitis. 

This  disease  is  commonly  knoAvn  as  thrush,  sprue,  soor,  or  muguet. 
It  occurs  in  the  mouth  in  the  form  of  yellowish-white  spots  and  is  due  to 
a  microbe.  A  fungus  was  first  discovered  by  Berg,  of  Stockholm,  and  called 
o'idium  albicans  by  Eobbin.  Forchheimer  states  that  the  fungus  is  found 
in  two  forms,  the  yeast  form  and  the  globulo-filimentous  form  (frequently 
called  mycelium).  "There  is  no  ascospore,  therefore.  Eoux  and  Linoissier 
state  that  the  fungus  is  not  a  saccharomyces.  The  chlamydospore  has, 
however,  not  been  satisfactorily  worked  out." 

Propagation  goes  on  in  three  "ways:  by  filaments  produced  from  conidia, 
by  isolated  conidia,  and  by  spores. 

Symptoms. — Local  symptoms  vary  with  the  severity  of  this  condition. 
At  times  no  symptoms  precede  the  appearance  of  these  small  spots.  The 
spots  are  grayish-white  or  creamy  in  color.  They  may  be  elevated  above 
the  surface  of  the  mucous  meml)rane.  They  are  not  confined  to  the  gums, 
but  appear  frequently  on  the  lips,  tonsils,  pharynx,  and  checks.  There  is 
a  fetid  breath  due  to  the  iniiaiued  gums.  Children  that  are  old  enough  to 
complain  do  not  descril)e  any  subjective  sym])toms.  The  lymphatic  glands 
are  always  enlarged  and  do  not  suppurate  Wlien  su|)i»uration  takes  place 
it  will   follow  after  the  disease  in  the  mouth  has  disappeared. 


226  DISEASES  OF  THE  MOUTH. 

Treatment. — PropJiylacUc  treatment  of  the  mouth,  consisting  in  the 
usual  hygienic  measures,  can  prevent  this  condition.  Aseptic  details  must 
be  rigidly  enforced  in  the  nursing  bottles  and  nipples  when  this  disease  is 
present. 

Treatment  consists  in  the  application  of  a  1  per  cent,  boric  acid  solu- 
tion as  a  mouth  cleanser,  followed  by  the  local  application  of  a  3  per  cent, 
chlorate  of  potassium  solution.  Where  a  specific  cause  exists,  such  as 
carious  teeth  or  dead  bone,  the  same  should  be  removed  before  attempting 
to  cure  this  condition. 

Croupous  Stomatitis^  or  Diphtheritic  Stomatitis. 

This  rare  condition  is  occasionally  met  with  in  children.  The  prog- 
nosis and  treatment  should  be  considered  just  the  same  as  though  we  were 
dealing  with  diphtheria  in  the  throat.  The  following  interesting  case  was 
sent  to  my  clinic  at  the  New  York  Post-Graduate  Medical  School  in 
1894:— 

The  child  was  seven  months  old^  female,  breast-fed,  had  always  been  in  good 
health.  No  family  histoiy  of  tuberculosis,  lues,  rheumatism,  or  epilepsy.  The  child 
was  vaccinated  when  about  six  months  old,  had  had  no  previous  illness  excepting 
slight  irritability  about  the  time  of  the  eruption  of  the  first  tooth.  It  has  two 
teeth,  incisors,  lower  jaw.  General  appearance  not  an£Emic  or  rachitic,  has  well- 
nourished  muscles  and  a  fair  amount  of  fat.  Skin  has  a  healthy  appearance.  Four 
other  children  in  same  family;  three  apparently  healthy,  the  fourth  is  convalescing 
from  an  attack  of  "sore  mouth."  The  infant  has  been  gaining  weight  regularly  since 
birth.     It  now  weighs  15  pounds  and  8  ounces. 

An  examination  of  the  infant  showed:  Two  large  patches — one  on  the  tip  of 
the  tongue,  the  other  on  the  soft  palate — which  were  irregular  in  outline,  yellowish- 
green  in  appearance.  Temperature  in  the  rectum  100  Vb°  F-,  at  11  a.m.;  pulse,  142; 
respiration,  39.  Cervical  glands  considerably  enlarged  on  both  sides.  No  history 
of  existing  infectious  disease  in  the  same  locality.  The  diagnosis  of  stomatitis 
ulcerosa  was  made  and  a  question  mark  (?)  entered  after. the  same.  Diphtheria 
was  suspected.  The  mother  was  cautioned  in  regard  to  the  other  children,  and  the 
case  carefully  watched.  I  again  saw  the  case  two  days  later  and  found  the  child 
in  a  worse  condition.  The  temperature  in  the  rectum  at  4  p.m.  was  102  75°  F.; 
pulse,  160;  small,  feeble,  but  quite  regular.  The  examination  of  the  mouth  showed 
an  extension  of  the  inflammatory  condition  of  the  patches,  now  involving  the  uvula 
and  left  tonsil.  The  pharynx  showed  an  abnonnal  redness,  but  no  membrane  was 
visible. 

The  mother's  breast  was  painful  on  palpation.  The  glands  were  distended 
with  milk,  and  the  axillaiy  glands  enlarged  and  tender  on  palpation.  The  mother 
complained  of  aching  in  her  limbs — a  "tired  feeling,"  as  she  called  it — and  ha^ 
chills,  altei-nating  with  fever.  Her  temperature  was  99  Vj"  F.  in  the  mouth. 
There  were  membranous  patches  around  one  of  her  nipples.  This  resembled  a 
cracked  nipple.  While  examining  the  infant's  mouth  I  saw  what  appeared  to  be 
membrane.  A  similar  condition  was  found  around  the  nipple.  I  inoculated  two 
agar-agar  tubes  and  placed  them  in  the  thermostat.  After  thirty-six  hours,  small 
colonies  of  both  streptococci  and  bacilli  could  be  seen.     On  staining  with  Loefller'a 


STOMATITIS  GANGRENOSA.  227 

alkaline  methylene  blue,  showed  distinct  semblance  to  Klebs-Loefiler  bacilli.  A 
culture  was  made  from  the  patch  in  the  mouth,  from  the  uvula,  and  also  from  the 
phaiynx;  The  tube  inoculated  with  the  uvula  patch  and  the  one  from  the  tongue 
contained,  in  almost  pure  culture,  the  characteristic  Klebs-Loeffler  bacilli.  The  usual 
method  of  treatment  and  active  stimulation  was  given.  Concentrated  liquid  diet 
(rectal  feeding)  was  given  when  the  infant  refused  the  breast.  An  important 
question  suggested  itself:  Shall  we  wean  the  infant?  or,  mother  and  infant  having 
the  same  disease,  could  the  infant  be  nursed  on  the  healthy  breast?  It  will  be 
remembered  that  only  one  nipple  was  diseased.  I  resolved  to  give  the  infant  the 
milk  of  the  healthy  breast  and  to  guard  against  another  sore  nipple  by  nursing 
through  a  glass  nipple  shield.  The  milk  in  the  diseased,  or  left,  breast,  was  drawn 
out  with  a  breast-pump  and  thrown  away. 

Three  weeks  after  the  apparent  cure  of  the  mother's  breast  and  also  after  the 
last  visible  membrane  from  the  infant's  throat  disappeared,  the  mother  complained 
that  she  slept  with  one  eye  open.  On  examination,  I  found  a  distinct  facial  paralysis 
on  the  right  side.  The  diagnosis  was  strengthened  by  the  sequel  in  tlie  case.  To 
sum  up:  I  believe  the  infant,  while  having  diphtheria,  infected  its  mother  tlirough 
the  fissure  of  the  breast  during  the  act  of  nursing.  Considering  the  physiology  of 
nursing,  we  know  the  role  played  by  the  tongue,  and  as  the  disease  was  first  mani- 
fested thereon,  it  can  be  readily  seen  how  this  miglit  have  been  inoculated  from 
tongue  to  the  bi-east  through  its  cracked  nipple. 

Syphilitic  Stomatitis. 

Primary  infection  in  syphilis  is  by  no  means  rare.  It  usually  occurs 
by  transmission  from  a  wet-nurse  suffering  with  syphilis. 

A  case  of  this  kind  was  seen  by  me  in  an  infant  nine  months  old.  This 
infant  was  accidentally  infected  by  a  woman  who  nursed  it  during  the  mothers 
illness.  She  had  erosions  (cracked  nipples)  and  did  not  know  that  she  suffered  with 
syphilis.  Her  own  child  died  of  distinct  syphilis,  having  had  pemphigus  and  the 
general  cachexia  so  common  in  luetic  conditions.  This  case  was  given  small  doses 
of  calomel,  and  given  a  bichloride  bath  (see  chapter  on  "Syphilis")  and  showed  signs 
of  improvement  almost  immediately.  In  the  mouth  of  this  child  the  ordinary  mucous 
patel:es  were  found. 

Treatment  is  that  of  syphilis,     (See  chapter  on  "Syphilis.") 

Stomatitis  Gangrenosa  (Xoma:  Caxcrum  Oris.^) 

This  disease  is  frequently  called  noma,  and  sometimes  cancrum  oris. 
Tt  is  characterized  by  a  gangrenous  destructive  process  located  on  the 
cheek.  Although  the  left  cheek  is  the  favorite  site  of  the  disease,  it  can 
frequently  be  found  on  both  cheeks.  The  writer  has  met  with  children 
suffering  from  this  disease  on  the  right  cheek.  Girls  are  more  liable  to 
noma  than  boys.  It  is  usually  secondary  to  some  infectious  disease,  and 
has  been  known  to  follow  typhoid  fever,  smallpox,  scarlet  fever,  measles, 
pertussis    and    allied    infectious    disorders.      We    must    therefore    assume 


'Elxtracted  from  the  American  Journal  of  the  Medical  Sciences,  April,  1902. 


228  DISEASES  OF  THE  MOUTH. 

that  the  infections  diseases  are  predisposing  factors  in  the  development  of 
this  disease. 

Some  authorities  claim  that  noma  frequently  is  a  sequel  to  infectious 
diseases. 

The  process  usually  commences  on  the  gums  or  the  inner  portion  of 
the  cheek,  and  spreads  very  rapidly  to  the  adjacent  tissues.  Thus  it  is 
that  it  will  destroy  the  inner  portion  of  the  cheek  and  spread  to  the  outside, 
causing  similar  destruction  to  the  healthy  tissues.  From  the  nature  of  the 
method  of  spreading  it  appears  to  be  of  a  specific  nature.  Whether  or  not 
a  specific  micro-organism  causes  this  disease  has  not  yet  been  definitely 
determined.  We  know,  however,  that  it  commences  similarly  to  a  diph- 
theritic process  and  spreads  in  the  same  manner.  Weak  children,  as  those 
above  mentioned,  that  have  passed  through  severe  infections,  are  the  ones 
usually  attacked  by  this  disease. 

Symptoms. — The  cheek  will  appear  swollen,  hard,  and  cedematous  to 
the  touch,  the  oedema  causing  such  swelling  that  frequently  the  eye  of  the 
afCected  side  cannot  be  opened.  There  is  a  decided  fetor  to  the  breath, 
which  is  often  the  first  symptom  noticed.  The  disease  spreads  very  rapidly 
from  the  gums  to  the  cheek.  Frequently  the  teeth  will  loosen  and  fall 
out.  The  latter  is  frequently  caused  by  the  previous  administration  of 
mercury.  Thus  it  is  that  great  care  should  be  used  in  giving  mercury  to 
children. 

That  it  is  not  an  inflammatory  disease  can  be  seen  by  the  fact  that 
the  temperature  is  rarely  or  never  above  normal.  The  swelling  can  best 
be  felt  by  opening  the  mouth  and  grasping  the  cheek  between  the  thumb 
and  forefinger.  The  skin  over  the  induration  is  frequently  mottled  with 
purple  spots  resembling  ecchymoses.  The  appetite  is  diminished,  partly 
due  to  the  fear  of  pain  caused  by  chewing. 

Some  authorities  state  that  children  so  aff'ected  have  diarrhoea.  Forch- 
heimer  believes  that  haemorrhages  rarely  occur,  owing  to  the  blood-vessels 
being  filled  with  thrombi. 

When  this  gangrenous  mass  discharges  we  will  find  a  dirty,  fetid 
saliva,  with  threads  of  broken-down  tissue.  The  cervical  glands  in  the 
immediate  vicinity  are  always  found  enlarged.  In  severe  cases  it  is  not 
rare  to  have  the  parts  ulcerate  and  even  perforate  the  cheek  after  several 
days.  When  the  disease  extends  inward,  not  only  does  periostitis  occur,  but 
necrosis  of  the  jaw-bone  has  been  noted.  When  the  disease  is  as  malignant 
as  has  just  been  described,  then  subnormal  temperature,  possibly  delirium, 
may  complicate  the  condition.  The  disease  may  extend  to  the  lungs,  caus- 
ing a  gangrenous  infiltration.  When  the  gangrene  affects  the  genitals  in 
girls,  then  a  serious  prognosis  must  be  given. 

Starr  maintains  that  noma  makes  its  appearance  uniformly  at  one 
point  on  the  cheeky  and  is  unilateral,  which  suggests  a  localized  causative 


STOMATITIS  GANGRENOSA.  229 

lesion.  The  most  natural  tlieoij,  that  of  embolism  of  a  largo  arterial 
branch,  due  to  weakness  of  the  cardiac  muscle  or  increased  coagulability 
of  the  blood — effects  of  the  primary  disease — is  untenable,  because,  with 
the  given  conditions,  emboli  ought,  at  least  occasionally,  to  be  found  in 
other  j^ositions,  which  does  not  happen.  It  is  necessary  to  look  rather  to 
the  nerves — namely,  the  trifacial,  the  facial,  or  the  vasomotors.  That  the 
gangrene  is  due  to  a  lesion  of  one  of  these  seems  to  be  borne  out  by  e.\2:)eri- 
ments.  Thus  Magendie  found  that  division  of  the  trifacial  in  dogs  caused 
destruction  of  the  corresponding  eyeball,  and  half  of  the  tongue  became 
dry,  brown,  and  fissured,  the  gums  spongy  and  hemorrhagic,  and  the  teeth 
loose.  "In  animals  tenacious  of  life — the  batrachians,  for  example — the" 
soft  portions  of  the  face  are  cast  off  in  shreds,  just  as  in  spontaneous  gan- 
grene.   After  three  or  four  weeks  only  one-half  of  the  face  remains." 

A  variety  of  bacteria  can  be  found  at  the  seat  of  lesion,  but  their 
presence  has  no  etiological  significance.  The  body  of  a  child  dead  from 
noma  has  a  gangrenous  odor  and  decomposes  quickly;  the  skin  is  shriv- 
eled and  the  face  and  the  feet  are  cedematous.  The  gangrenous  parts  are 
converted  into  a  blackish-brown  mass,  and  the  maxillary  bones  are  naked, 
brownish  in  color,  and  brittle.  The  nerves,  when  examined  microscopic- 
ally, are  yellowish  in  color  but  unaltered  in  structure,  and  the  blood-vessels 
are  thickened  and  filled  with  thrombi.  In  the  uninvolved  parts  of  the 
cheek  there  is  a  dense  exudation,  while  the  palate,  tongue,  and  tonsils  are 
swollen  and  covered  with  black  scales  and  crusts.  The  lungs  are  the  seat 
of  hajmorrhagic  infarctions,  lobular  or  metastatic  lobar  pneumonia,  and 
sometimes  gangrene.  The  intestines  are  catarrhal.  Evidences  of  the  pri- 
mary disease  may  also  be  present ;  for  example,  the  lesions  of  typhoid  fever 
or  dysentery. 

The  following  case  will  illustrate  the  condition  described  : — • 

Elsie  G.,  aged  7  years,  was  seen  by  mo  in  Januaiy,  1!)00.  The  child  liad  coni- 
phiined  of  severe  headache  for  three  or  four  days,  and  was  very  feverish.  Her 
niotlier  became  alanned  because  of  persistent  vomiting.  She  stated  that  the  child 
vomited  at  least  six  times  in  twenty-four  hours.  She  complained  of  feeling  fatigued 
and  had  pains  in  her  arms  and  legs. 

Small  doses  of  quinine  were  given  the  cliiid,  but  did  not  seem  to  relieve  the 
present  condition. 

The  child  was  nursed  for  ten  months,  and  was  a  strong  bal>y  up  to  this  time; 
dentition  commenced  at  the  seventh  month;  the  child's  muscles  and  bones  were 
well  developed;  there  were  no  evidences  of  rickets;  the  first  two  years  were  passed 
without  any  sickness  except  an  oeca.sional  attack  of  constipation.  The  child  vvalkeJ 
at  the  end  of  the  first  year  and  commenced  talking  at  its  fourteenth  month.  Twenty 
teeth — "milk  teeth" — appeared  at  the  end  of  two  years.  The  child  had  measles  in  its 
third  year,  which  left  a  bronchitis:  the  motlier  states  that  this  same  cough  recurs 
every  winter.  The  cliild  has  had  whooping-cough,  lasting  four  months,  which  was 
so  violent  that  it  had  ei)istaxis  almost  every  day  for  one  month.  This  whooping- 
cough  was  so  severe  that,  in  addition  to  the  nose-bleed,  the  child  vomited  almost 


230 


DISEASES  OF  THE  MOUTH. 


continuously.  From  loss  of  sleep,  in  addition  to  the  above-named  symptoms,  the 
child  commcncid  to  emaciate.     This  was  at  the  end  of  her  fifth  year. 

She  lost  twelve  pounds  in  two  months,  and  the  mother  states  tliat  since  that 
time  she  has  been  veiy  puny  and  delicate.  There  ia  also  a  hernia  directly  traceable 
to  the  vioknt  paroxysms  of  cough. 

The  mother  suspected  the  child  was  sutlering  from  malaria,  or  possibly  an 
attack  of  grip.  When  the  child  was  undressed  an  eruption  was  found  all  over  the 
body,  which  was  that  of  typical  scarlet  fever.  The  throat  was  filled  with  evidences 
of  pseudo-membranous  patches  which  were  distinctly  scarlatinal  in  character.  Tlie 
temperature  was  103.4°  F.,  taken  in  the  reitum;    pulse,  128:    respiration    22.     The 


Fig.  (iO. — Case  of  Stomatitis  Gangrenosa  (Noma)  Following  Scarlet 
Fever.  The  picture  shows  the  imilateral  gangrenous  condition  involving 
the  right  check  and  the  lips.  Case  recovered.  Clinical  history  given  in 
the  text.      (Original.) 


child  was  p\tt  to  bed  and  an  expectant  plan  of  treatment  ordered,  in  addition  to  a  very 
light  liquid  diet  consisting  of  soup,  milk,  buttermilk,  broth.  Nothing  else  was 
allowed;  no  solids  were  given.  For  the  thirst  I  ordered  orange  juice  and  apple 
sauce.  Small  doses  (wine-glasses)  of  citrate  of  magnesia  were  given  for  their  laxa- 
tive and  diuretic  effects. 

Desquamation  followed  in  the  fecond  week  in  the  usiial  manner.  The  urine 
showed  traces  of  albumin  in  the  second  week,  which  increased  until  that  time — 6 
per  mille,  according  to  Eschbach's  albuniinometer — hyaline  and  epithelial  casts  were 
found  in  great  numbers.  There  were  also  large  quantities  of  blood-corpuscles  visible 
under  the  microscope.  The  urine  was  quite  red  from  the  blood  that  it  contained. 
At  the  end  of  the  third  week  tliere  was  quite  an  anuria.  This  latter  condition  was 
relieved  by  the  application  of  several  dry-cups  over  the  region  of  the  kidneys.  Five 
to    10   grains    of   diuretin   internally    were   ordered    every   four   hours.      Citrate   of 


EPITHELIAL  DESQUAMATION  OF  THE  TONGUE.  231 

potash  was  giv^en,  5-grain  doses  combined  with  large  quantities  of  Apollinaris  and 
lithia  water.     After  three  weeks  of  patient  treatment  the  child  recovered. 

The  heart  sounds  were  not  only  very  feeble,  but  thready,  and  a  loud,  blowing, 
haemic  murmur,  which  was  attributed  to  the  anaemic  condition,  was  audible.  Iron 
was  given  in  the  form  of  the  syrup  of  iodide  of  iron;  hypophosphites  were  also 
administered  as  restoratives.  Convalescence  lasted  in  all  until  April,  a  period  of 
almost  three  mouths  from  the  time  of  the  child's  first  illness.  About  this  time  she 
complained  of  pain  in  the  gums  and  on  the  cheek  while  chewing.  Later,  the  foul 
breath  attracted  attention.  At  first  this  condition  was  attributed  to  the  teeth, 
but  a  dentist  who  saw  the  child  found  the  teeth  and  gums  healthy.  The  ulceration, 
which  had  now  become  quite  marked,  from  the  size  of  a  silver  dollar,  spread  with 
remarkable  rapidity.  Its  color  was  that  of  a  dirty,  blackish-gray,  and  had  purpuric 
spots  scattered  around  the  edges  of  this  ulceration,  resembling  subcutaneous  haemor- 
rhages. On  examining  it  considerable  fluid,  which  was  very  foul  smelling,  exuded 
on  pressure.  Antiseptic  lotion,  consisting  of  50  per  cent,  peroxide  of  hydrogen 
diluted  with  water,  was  ordered  as  a  mouth  wash.  The  child  was  told  to  rinse  the 
mouth  every  half-hour,  especially  after  eating.  The  gangrene  extended  to  the  out- 
side of  the  cheek,  involving,  as  can  be  seen  by  the  illustration,  almost  the  whole 
cheek.  The  picture  was  taken  after  the  child  had  had  its  mouth  and  its  cheek  thor- 
oughly cauterized  by  using  the  Paquelin  cautery.  Ichthyol  was  applied  in  the  fol- 
lowing manner:  — 

IJ  Ichtliyol  one  part  and  lanolin  ten  parts. 

M.  Ft.  ungt.  Sig. :  Apply  over  the  whole  of  the  gangienous  surface  by 
rubbing  the  parts  thoroughly,  the  same  to  be  repeated  at  least  three  or  four  times 
a  day. 

The  ichthyol  seemed  to  serve  remarkably  well  in  this  case.  The  same  was 
continued  for  about  three  weeks,  when  the  child  was  discharged  as  cured. 

Epithelial  Desquamation   (Geographical  Tongue). 

A  very  common  condition  consists  of  epithelial  desquamation  of  the 
tongue,  giving  rise  to  irregular,  round  or  crescent-shaped  patches.  The 
borders  of  these  patches  are  surrounded  by  a  thickish,  grayish  margin.  The 
center  has  a  glazed  app(>aranco.  From  the  irregular  outline  resembling  a 
map  the  name  of  geographical  tongue  originates. 

There  are  usually  two  or  more  of  those  red  patches  seen  at  one  time. 
They  last  weeks  and  months.  I  have  met  these  cases  among  the  poorest 
iiygienic  surroundings  and  have  seen  the  same  condition  among  the  wealthy. 
Malnutrition  seems  to  be  associated  in  all  my  cases.  I  have  frequently  seen 
cases  of  this  kind  among  the  children  suffei'ing  with  diphtheria  at  the 
Willard  Parker  Hospital,  especially  during  convalescence.  The  following 
case  illustrates  this  condition  : — 

Minnie  IT.  Fourteen  months  old.  Has  been  in  delicate  health  since  birth. 
Although  breast-fed,  has  always  been  constipated  and  suffered  with  gastritis,  and 
vomiting  occasionally. 

She  is  very  anaemic.  Can  neither  stand,  walk,  nor  talk.  Dentition  has  been 
delayed;  there  is  no  sign  of  teeth.     The  tongue  shows  four  large  irregular  shaped 


232  DISEASES  OF  'I'lIK  MOUTH. 

patches  and  two  snialkr  ones  in  tlie  .et'nter.  They  apiioar  as  thoujrli  a  eoaU'd 
toniifuc  had  iiregnhir  patches  of  red,  and  sliining  flesh  interspersed.  Diagnosis,  rickets 
and  geographical  tongue. 

Treatment. — Increase  tlie  proteids  and  fats  to  stimulate  nutrition. 
Cleanse  the  tongue  with  boric  or  tannic  acid  solution.  Most  authors  advise 
no  treatment. 

Congenital  HYrEiiTKOPHY  of  the  Tongue. 

A  thickened  swollen  tongue  is  always  seen  in  sporadic  cretinism.  (Sec 
cliapter  on  "Cretinism.")  The  specific  thyroid  treatment  will  usually 
modify  this  enlargement.  When  diseased  lymphatics  exist  we  may  have 
a  lymphangioma.  Such  conditions  arc  rare,  and  if  present  require  surgical 
treatment. 

Bifid  Tongue. 

Brothers  rc^iortcd  a  case  of  this  kind  to  the  New  York  Pathological 
Society.  The  child  was  one  mouth  old,  had  a  cleft  tongue  and  a  fissure  of 
the  soft  palate; 

Bifid  Uvula. 

This  condition  is  occasionally  seen.  I  have  seen  hi  fid  uvula  several 
times  without  cleft  palate.  Some  authors  report  the  co-existence  of  bifid 
uvula  with  cleft  palate.    It  requires  no  treatment. 

Glossitis. 

An  inflammation  of  the  tongue  is  very  rare  in  children.  Some  authors 
state  that  it  is  due  to  traumatism,  such  as  biting  the  tongue  in  an  epileptic 
fit,  or  a  ragged  sharp  tooth  nuiy  infect  the  tongue  and  cause  inflammation. 
Any  irritation,  such  as  caustic  acids  or  alkalies,  may  cause  inflammation. 

The  following  case  occurred  in  my  private  2:)ractice: — 

A  child  1  jear  old  was  hottle-fed,  and  suffered  with  severe  constipation.  Ho 
was  backward  in  development,  had  no  teeth,  could  ncitiier  walk  nor  talk.  Several 
adults  in  the  family  had  influenza  and  the  child  was  exposed  and  infected.  The 
fever  reached  104°  F.  There  was  anorexia,  cough,  and  running  of  the  nose.  Tlie 
tongue  was  thickened  and  inflamed  and  pvotruded  from  the  mouth.  He  refused  to 
take  any  food  and  seemed  relieved  when  a  piece  of  ice  was  placed  on  the  tongue.  Ice 
cream  was  ordered  to  nourish  and  cool  at  the  same  time.  Rectal  suppositories  con- 
Uiining  aconite,  1  minim,  and  sodium  salicylate,  3  grains,  were  ordered  every  two 
hours.  Under  this  treatment,  aided  by  ice  applied  on  the  tongue  and  an  ice  collar 
on  the  neck,  the  swelling  of  the  tongue  disappeared  in  about  four  days. 

Eanula. 

A  swelling  in  the  floor  of  the  mouth,  located  on  cither  side  of  the 
fra3num,  is  frequently  met  with  in  children.     It  is  a  cyst  varying  in  size, 


PLATE    VII 


Greographical  Toiiyue,  or  Epithelial  l)es4uaiiiation. 
(Original.) 


ALVEOLAR  ABSCESS.  233 

and  is  due  to  an  occlusion  of  the  duct  leading  into  the  mouth  from  the 
sublingual  gland. 

Character. — It  may  be  simple  or  multilocular.  It  may  be  of  suc-h  pro- 
portions as  to  interfere  with  proper  nutrition. 

Symptoms. — The  symptoms  are  those  of  a  mechanical  ol)struction  of 
a  nou-inriammatory  character.  It  is  painless,  soft,  fluctuating,  and  con- 
tains mucus.  The  color  of  the  growth  is  the  same  as  that  of  the  adjacent 
parts. 

Treatment. — An  incision  should  be  made  to  evacuate  the  contents  of 
the  sac.  The  interior  of  the  sac  should  l)e  cauterized  with  iodine  or  nitrate 
of  silver.    In  some  instances  the  Paquelin  cautery  may  be  required. 

Alveolar  Abscess. 

When  tliere  is  defective  hygiene  in  the  mouth  and  tlie  teeth  are  not 
properly  cleaned,  caries  of  the  teeth  results.  The  carious  condition  fre- 
quently sets  up  an  inflammation  and  pyogenic  bacteria  gaining  entrance 
cause  abscess  formation  at  the  root  of  the  tooth. 

Symptoms. — The  symptoms  are  pain,  swelling,  fever,  interference  with 
feeding,  foul  breath,  and  general  constitutional  disturbances.  The  diag- 
nosis can  be  made  by  the  presence  of  fluctuation  in  the  mouth,  by  the 
swollen  face,  mouth,  and  jaw. 

Treatment. — Locally,  warm  (dry)  chamomile  bag  or  warm  (moist) 
flaxseed  poultices  will  have  a  soothing  efEect,  used  externally  over  the  swell- 
ing. Kinsing  the  mouth  with  warm  chamomile  tea  to  which  a  few  drops 
of  listerine  has  been  added  is  grateful.  Painting  the  gums  with  equal  parts 
of  tincture  of  iodine  and  tincture  of  opium  every  hour  will  relieve  pain. 
If  fluctuation  is  detected  an  incision  should  be  made  into  the  gums  on  the 
inner  surface,  and  the  pus  evacuated.  If  this  condition  is  neglected  the 
periosteum  of  the  jaw  may  be  involved  and  the  pus  will  burrow*  and  evacuate 
itself  spontaneously,  leaving  a  disagreeable  fistula.  Cases  have  been  reported 
where  neglect  of  this  condition  has  resulted  in  necrosis  of  the  jaw. 


CHAPTEE  II. 

DISEASES  OF  THE  (ESOPHAGUS. 

Acute  Oesophagitis. 

An  inflammation  may  extend  from  the  pharynx  into  the  oesophagus. 
When  such  conditions  arise  the  symptoms  of  pain  on  swallowing  are  asso- 
ciated with  fever.  The  treatment  consists  in  giving  bland  food,  milk, 
seltzer,  and  alkaline  waters  or  water  containing  bicarbonate  of  soda. 

Croupous  or  Diphtheritic  (Esophagitis. 

Diphtheria  can  invade  the  oesophagus  as  well  as  it  can  spread  to  the 
larynx.  Some  authors  describe  croupous  inflammatory  patches  in  the 
oesophagus.  I.  have  seen  diphtheria  of  the  oesophagus  and  also  a  diph- 
theritic patch  post-mortem  in  the  stomach  of  this  same  case.  Such  a  con- 
dition is  invariably  serious  and  recovery  is  rare.  The  treatment  of  dipli- 
iheria  affecting  the  oesophagus  is  the  same  as  that  described  in  the  chapter 
on  "Diphtheria."  When  dysphagia  occurs  and  there  is  an  interference  with 
deglutition,  rectal  feeding  may  be  demanded  to  save  life. 

If  severe  pain  exists  give  morphine  or  codeine  in  suitable  doses.  Nau- 
sea and  vomiting  can  best  be  controlled  by  giving  large  doses  of  chloral.  If 
an  oesophageal  stricture  remains  then  surgical  treatment  will  be  required 
for  which  the  reader  is  referred  to  modern  text-books  on  surgery. 

Eetro-cesophageal  Abscess. 

This  condition  may  follow  measles,  scarlet  fever  or  diphtheria,  in  fact, 
it  may  be  associated  with  any  infectious  disease.  As  a  rule  this  disease  con- 
sists of  a  breaking  down  of  the  lymph  glands  ending  in  suppuration.  In 
a  case  seen  by  me  the  streptococcus  was  found.  This  condition  is  also 
frequently  associated  with  tubercular  conditions.  The  following  case  will 
illustrate  the  type  most  frequently  met  with : — 

I  was  called  in  consultation  with  Dr.  S.  Brothers  to  see  a  child  3  years  old 
with  the  following  history: — 

There  was  fever,  an  iiTitant  cough,  stertorous  breathing,  and  evidence  of 
obstruction  pointing  to  the  larynx.  The  neck  was  swollen  and  the  glands  enlarged. 
The  temperature  was  102°  F. ;  pulse,  130;  respiration,  3G.  At  first  the  case  resem- 
bled one  of  larj'ngeal  stenosis  as  is  usually  found  in  diphtheria.  The  dyspnoea  was 
so  marked  that  intubation  was  suggested.  The  symptoms  of  dyspnoea  continued 
and  an  incision  was  made  into  the  posterior  pharyngeal  wall.  The  abscess  cavity 
extended  into  the  oesophagus.  Caries  of  the  dorsal  vertebrae  was  associated  with 
this  condition.     The  child  died  from  inanition.     The  tubercular  process  was  evidently 

(334) 


FOREIGN  BODIES  IN  THE  CESOPHAGUS.  235 

responsible  for  the  abscess,  which  consisted  of  pus  and  large  curded  masses.  The 
diagnosis  was  made  after  a  careful  study  of  the  case.  It  is  not  an  easy  matter  to 
diagnose  this  condition,  as  it  is  absolutely  impossible,  in  some  cases,  to  reach  tiie 
abscess  cavity  by  a  digital  examination  of  the  pharynx. 

In  the  case  above  reported  the  dysiDncea  was  very  alarming.  The  litera- 
ture records  cases  of  spontaneous  evacuation  of  the  abscess  into  the  oesoph- 
agus resulting  in  recovery,  but  usually  these  cases  end  fatally.  The  treat- 
ment is  surgical,  and  tuberculosis,  if  present,  requires  tlii;  u<uai  form  of 
treatment.     (See  chapter  on  "Tuberculosis.^') 

Foreign  Bodies  in  the  Q^sophagus. 

I  have  frequently  been  consulted  regarding  the  removal  of  buttons, 
coins,  etc.,  which  were  swallowed.  The  habit  of  children  to  put  everything 
into  the  mouth  should  be  remembered  when  buying  toys. 


Fig.  61. — Hineed  Bucket. 


The  best  method  of  extracting  foreign  bodies  in  the  rcsophagus  is  by 
means  of  the  hinged  bucket,  also  known  as  the  "coin  catcher/' 


CHAPTER  III. 
DISEASES  OF  THE  STOMACH. 

The  Infantile  Stomach. 

The  infantile  stomach  is  vertical  and  cylindrical  and  the  fundus  but 
little  developed.  Thus,  whenever  there  is  a  tendency  to  vomit,  the  anti- 
peristaltic motions  do  not  press  against  the  fundus,  but  directly  upward. 
There  is,  therefore,  rather  an  overflow  than  a  vomiting  of  the  gastric  con- 
tents;  this  takes  place  so  easily  that  the  babies  are  not  disturbed  by  it.^ 

Anatomy. — The  muscular  development  is  weakest  at  the  fundus.  Ac- 
cording to  Fleischmann,  the  oblique  and  the  longitudinal  fibers  described 
by  Henle,  which  have  their  origin  at  the  pyloric  opening,  "do  not  exist  in 
the  infant."  The  investigations  of  Leo  and  von  Puteren  show  that,  in  spite 
of  this  lack  of  muscular  development,  the  stomach  of  a  nursing  infant  is 
emptied  in  one  and  a  half  or  two  hours.  With  food  that  is  more  difficult 
to  digest,  the  gastric  contents  are  propelled  more  slowly. 

The  Mucous  Membrane  of  the  Stomach. — The  mucous  glands  are  far 
more  numerous  on  the  pars  pylorica  than  in  adults,  whereas  they  are  far 
fewer  in  number  at  the  cardia. 

The  mucous  membrane  of  the  infant  secretes  gastric  juice  which,  in 
general,  is  similar  in  properties  to  that  of  the  adult.  The  amount  of  accre- 
tion in  the, infant  is  far  less  than  in  the  adult,  while  its  chemical  constitu- 
tion is  the  same,  namely:  pepsin,  lab-ferment,  and  acids.  The  exact  pro- 
portion of  the  ferment  and  pepsin  has  not  yet  been  studied  sufficiently  to 
admit  of  any  positive  deductions  being  made. 

Physiology. — It  is  very  important  to  know  that  the  mucous  membrane 
of  the  mouth  is  practically  dry  at  birth;  the  secretion  of  saliva  is  very 
small,  and,  according  to  Korowin  and  Zweifel,  increases  toward  the  end  of 
the  second  month. 

The  fermentative  (sugar-forming)  property  of  saliva,  which  is  trifling 
at  the  commencement,  increases  with  the  quantity  of  the  saliva  secreted. 
This  is  essentially  true  of  other  secretions;  thus,  the  pancreatic  juice  does 
not  have  the  same  emulsifying  properties  in  the  infant  as  in  adults. 

The  nursing  or  sucking  center  is  located,  according  to  experiments 
made  on  animals  by  Basch,  in  the  medulla  oblongata  on  the  inner  side  of 
the  corpus  restiforme. 

The  sucking  act  is  reflex;  according  to  Auerbach,  the  muscles  of  the 
tongue  participate  most  actively. 


» Jacobi,  "Therapeutics  of  Infancy  and  Childhood,"  page  25. 
(236) 


PHYSIOLOGY  OF  THE  STOMACH.  237 

Acids  in  the  Infant's  Stomach. — The  gastric  contents  in  a  nursling 
contain  two  acids:  (1)  hydrochloric  acid;  (2)  lactic  acid.  The  relative 
acidity  is  smaller  than  in  adults,  the  highest  point  being  reached  one  and 
a  half  hours  after  nursing.  According  to  von  Puteren,  the  acidity  is  two 
{)Dd  one-half  to  three  times  as  small  as  in  the  stomach  of  adults.  Accord- 
ing to  Leo,  the  acidity  of  the  gastric  juice  of  nurslings  1  V2  hours  after 
drinking  is  only  0.13  per  cent.,  whereas,  in  the  adult,  after  the  same  time, 
the  acidity  is  from  1.5  to  3.2  per  cent.  According  to  Wohlmann,  free  HCl 
can  be  found  in  healthy  nurslings  from  1  V4  to  2  hours  after  taking  food. 
The  percentage  of  free  HCl  ranges  from  0.83  to  1.8  per  cent. 

Lactic  Acid. — The  quantity  of  lactic  acid  is,  according  to  Heubner, 
between  0.1  and  0.4  per  cent. 

Pepsin  and  Hydrocldoric  Acid. — There  are  two  chief  functions  of  the 
pepsin  and  hydrochloric  acid  which  are  the  same  in  both  infant  and  adult: 
First,  the  power  of  killing  bacteria :  a  real  bactericidal  power.  Second,  as 
a  solvent  for  albumin.  Thus,  it  is  apparent  that  pathogenic  micro-organ- 
isms that  might  have  entered  the  stomach  can  be  destroyed,  although  we 
know  the  small  quantity  of  acid  is  hardly  able  to  cope  with  large  quantities 
of  food  contaminated  with  bacteria. 

Unorganized  Ferments. — The  unorganized  ferments  seem  to  be  nitro- 
genous bodies;  their  exact  composition  is  unknown,  and  it  is  doubtful  if 
they  have  ever  been  obtained  perfectly  pure  (Landois  and  Stirling). 

Action  of  the  Saliva  on  Various  Bacteria. — Triolo  describes  a  series 
of  ii^eresting  experiments  with  saliva.  He  first  irrigated  the  mouth  with 
bichloride  or  permanganate  of  potash  solution,  followed  this  by  irrigation 
with  sterilized  water  until  the  disinfecting  substances  were  removed,  and 
then  inoculated  the  surface  of  various  culture-media  with  the  sputum.  His 
results  proved  that  saliva  possesses  a  distinct  bactericidal  property,  for 
cultures  of  five-day-old  bacteria  were  destroyed,  as  well  as  fresh  bacteria 
eighteen  hours  old. 

This  property,  however,  was  lost  when  saliva  was  filtered.  The  saliva 
of  the  parotid  and  submaxillary  glands,  taken  singly,  were  equally  effica- 
cious as  their  combined  secretion.  He  believes  that  the  greatest  bactericidal 
action  is  due  to  the  secretion  of  the  mucous  glands  in  the  mouth. 

The  Influence  of  Gastric  Juice  on  Pathogenic  Germs. — Gastric  juice  is, 
according  to  the  experiments  of  Drs.  Kurlow  and  Wagner,  an  exceedingly 
strong  germicidal  agent,  and  when  living  bacilli  get  into  the  intestinal 
canal  it  is  due  to  various  conditions  entirely  independent  of  the  gastric 
juice.  When  the  latter  is  normal  and  in  full  activity,  only  the  most  prolific 
microbes — such  as  tubercle  bacilli,  the  bacilli  of  anthrax,  and  perhaps  the 
staphylococci — escape  its  destructive  action ;  all  others  are  destroyed  in  less 
than  half  an  hour.  Similar  influences  exist  in  the  intestines,  as  proved  by 
inoculation  with  the  cholera  bacilli. 


238 


DISEASES  OF  THE  STOMACH. 


TABnTC  No.   53. — Showing  the  Unorganized  Ferments  Present  in  the  Body 
and  Their  Actions. 


Fluid  or  Tissues. 

P'erment. 

Actions. 

Saliva    .    .    • 

Ptyalin 

Converts  starch  chiefly  into  mal- 
tose. 

Gastric  juice    . 

1.  Pepsin 

2.  Milk-curdling 

3.  Lactic-acid  ferment.      .    .    . 

4.  Fat  splitting 

Converts  proteids  into  peptones  in 
an  acid  medium,  certain  by- 
products being  formed. 

Curdles  casein  of  milk. 

Splits  up  milk  sugar  into  lactic 
acid. 

Splits  up  fats  into  glycerine  and 
fatty  acids. 

1.  Diastasic,  or  amylopsin    .    . 
2    Trypsin 

Converts  starch  chiefly  into  mal- 
tose. 

Changes  proteid  into  peptones  in 
an  alkaline  medium,  certain 
by-products  being  formed. 

Emulsifies  fat. 

Splits  fat  into  glycerine  and  fatty 
acids. 

Curdles  casein  of  milk. 

Pancreatic  juice  . 

3.  Emulsive  (?) 

4.  Fat-splitting  or  steapsin  . 

5.  Milk-curdling 

Intestinal  juice 

1.  Diastasic 

2.  Proteolytic 

3.  Invertin • 

4.  Milk-curdling 

Does  not  form  maltose,  but  mal- 
tose is  changed  into  glucose. 

Fibrin  into  peptone  (?). 

Changes  cane-sugar  into  grape- 
sugar. 

In  small  intestine  (?). 

Blood     ..... 
Chyle        .... 
Liver  (?)  .... 

Milk 

Most  tissues .    .    . 

Diastasic  ferments     .... 

Muscle 

Uriue 

Pepsin  and  other  ferments  . 

Blood 

Fibrin- forming  ferment    . 

Judging  from  the  results  of  experiments  made  by  Zagari,  Straus,  and 
Wurtz,  who  exposed  various  pathogenic  organisms,  among  others  that  of 
tuberculosis,  to  the  action  of  gastric  juice,  we  must  come  to  the  conclusion 
that,  so  long  as  the  gastric  juice  retains  a  sufficient  degree  of  acidity,  tuber- 
culosis of  the  alimentary  canal  will  be  unlikely  to  occur. 

Albumin  and  the  Gastric  Juice. — Another  property  of  gastric  juice  in 
infants  is  the  transformation  of  albumin  in  the  following  manner:    (1) 


STOMACH  CAPACITY.  239 

filbumose;  (2)  then  peptone;  (3)  and  lastly  syntonin.  It  is  tlms  appa- 
rent that,  although  the  infantile  stomach  plays  a  subordinate  role  as  a  nour- 
ishing organ,  it  cannot  be  denied  that  fluid  substances — like  water,  a  solu- 
tion of  salt,  and  solution  of  sugar — are  absorbed,  and  in  a  less  degree  albu- 
min also.  The  relative  size  and  capacity  of  the  stomach  prevent  the  func- 
tion from  being  as  thoroughly  developed  as  in  the  adult. 

Stomach  Capacity. 

At  birth  the  infant's  stomach  has  a  capacity  of  from  9  to  11  drachms, 
or  35  to  43  cubic  centimeters.  At  the  end  of  one  month  it  is  about  3  ounces, 
or  60  cubic  centimeters. 

At  the  end  of  three  months  the  gastric  capacity  is  about  four  times 
the  amount  at  birth.  The  very  rapid  increase  from  birth  to  this  time  soon 
ceases,  and  the  stomach  capacity  grows  in  size,  but  at  a  much  slower  rate 
of  development  (Baginslcy). 

The  series  of  experiments  at  the  Children's  Hospital  of  St.  Petersburg, 
made  by  Ssnitkin,  showed  that  the  weight,  and  not  the  age,  determined  the 
capacity  of  the  stomach,  and  should  be  used  as  a  guide  for  the  quantity  of 
infant-food  required. 

If  the  normal  (initial)  weight  of  an  infant  is  3000  to  4000  grams,  or 
about  6.6  to  8.8  pounds,  then  Vioo  part,  plus  the  daily  increase  in  weight 
added,  which  normally  amounts  to  from  V3  to  1  ounce,  would  give  the 
amount  of  food  required. 

Biedert  also  regards  the  body  weight  as  an  important  factor  in  deter- 
mining the  amount  of  milk  to  be  given.  Baginsky  argues  that,  while  this 
rule  will  hold  good  for  a  great  many  infants,  he  must  insist  upon  relying 
upon  the  scales  to  show  just  how  much  nutriment  has  been  digested,  and 
thus  a  regular  system  of  weighing,  plus  the  inspection  of  the  stools,  will 
aid  in  establishing  the  quantity  of  food  necessary.  "There  is  no  unanimity 
among  experienced  clinical  observers  upon  the  subject  of  infant-feeding." 
The  majority  of  clinicians  the  world  over  order  cows'  milk  in  varying 
dilutions.  Some  use  the  cereals — like  wheat,  barley,  rice,  and  farina — to 
dilute  and  subdivide  the  curd.  Other  clinical  observers — Budin  and  Variot, 
French  observers — advise  giving  infants,  at  birth,  whole  milh;  that  is,  pure, 
undiluted  coivs'  milh. 

The  following  illustrations  will  serve  to  show  the  difference  in  tlie 
capacity  of  infants'  stomachs  at  various  ages,  talcen  by  the  author  at  the 
morgue  of  Bellevue  Hospital. 


Fig,  62. — Infant's  Stomach.  Actual  Size.  From  a  Case  of  Malnutrition.  Capacity, 
About  2  Ouuces.  When  Stomach  was  Filled  it  Ueld  4  Ouuces  Easily.  (Author's  Col- 
lection.) 


^ 


Fig  63.— Infant's  Stomach.  Actual  Size,  Died  Suddenly  from  Convulsions.  Age 
Seven  Months.  Cause  of  Death,  Etlampsia.  Capacity  when  Filled  with  WaUr,  8% 
Ounces.    (Drawn  from  Specimen  in  Author's  Collection.) 


(240) 


.Fig.  64.— Infant's  Stomach.  Capacity,  10  Ounces.  Age  of  Child,  Eleven 
Months.  Cause  of  Death,  Enteritis.  (Drawn  from  Specimen  in  Author's  Col- 
lection.) 


J 


y 


\ 


Fig.  65.— Capacity  of  Measurement,  14  Ounces.    Diseased  Condition.    Normal  Capacity, 
Holding  About  2  Ounces,  or  50  Cubic  Centimeters.    (Author's  Collection.) 


(241) 


242  DISEASES  OF  THE  STOMACH. 


Significance  of  Vomiting. 

Vomiting  is  a  reflex  act.  It  can  be  produced  directly  by  irritating 
the  stomach,  as,  for  example,  when  mustard  is  swallowed.  It  can  also  be 
produced  by  a  great  many  vegetable  products,  as,  for  example,  by  ipecac 
root.  Mineral  poisons,  such  as  sulphate  of  zinc  or  turpeth  mineral,  or  sul- 
phate of  copper,  will  produce  violent  emesis.  Bacterial  fermentation  from 
stagnant  food  can  also  produce  vomiting.  These  causes  are  therefore  direct 
in  their  action  and  produce  immediate  results.  It  is  a  great  mistake  to 
look  upon  the  stomach  or  the  stomach  contents  as  the  etiological  factor  in 
vomiting,  and  as  the  only  organ  capable  of  producing  emesis. 

The  toxins  in  the  blood  of  many  acute  infectious  diseases  produce  vom- 
iting. One  of  the  earliest  symptoms  of  scarlet  fever  is  vomiting.  Several 
days  before  the  eruption  of  scarlet  fever  appears,  vomiting  of  a  most  violent 
nature  generally  occurs.     This  is  no  doubt  due  to  toxaemia. 

An  irritation  of  the  vagus  or  the  pneumo-gastric  nerves  can  result  in 
vomiting.  Any  irritation  brought  about  through  the  central  nervous  sys- 
tem will  cause  vomiting;  thus  it  is  that  shock,  fright,  or  disturbance  of 
metabolism  may  produce  vomiting  of  a  most  serious  nature. 

Giddiness,  caused  by  swinging  or  a  rolling  motion,  as  on  a  ship,  may 
produce  cerebral  hypersemia,  ending  in  vomiting.  When  a  child  falls  on 
the  back  of  its  head  and  produces  concussion  of  the  brain,  we  have  con- 
tinued vomiting  as  a  first  symptom.  When  vomiting  persists  in  spite  of 
gastric  treatment,  meningeal  disease  should  be  suspected.  In  meningitis, 
especially  in  hydrocephalus,  vomiting  is  a  frequent  symptom.  The  writer 
does  not  presume  that  any  physician  will  diagnose  brain  fever,  scarlet  fever, 
or  gastric  fever  by  the  single  symptom  of  vomiting. 

On  the  other  hand,  it  is  well  to  know  that  vomiting,  with  a  suspicious 
rash  and  a  sore  throat,  will  strengthen  the  suspicion  of  an  existing  scarlet 
fever.  A  rule  followed  by  the  writer  is  to  lay  considerable  stress  on  vom- 
iting. It  means  nothing  if  we  are  dealing  with  a,  spoiled  stomach  following 
a  large  dish  of  plum  pudding.  But  woe  to  the  physician  who  gives  a  good 
prognosis  where  vomiting  is  an  early  manifestation  of  intracranial  disease 
that  ends  fatally. 

Acute  Gastric  Catarrh  (Dyspepsia — Gastritis). 

One  of  the  most  frequent  diseases  met  with  in  infants  or  young  chil- 
dren is  dyspepsia.  This  is  due  to  improper  feeding  of  both  quality  and 
quantity  of  the  food.  Nursing  children  are  very  often  seen  suffering  with 
this  disease,  especially  among  the  tenement  population. 

That  the  immediate  surroimdings,  so-called  poor  hygiene,  has  some 
bearing  on  the  development  of  this  disease  is  certain.  Children  reared  in 
unsanitary  apartments  cannot  digest  bieast-niilk  as  well  as  children  living 


1> 


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ACUTE  GASTRIC  CATARRH.  243 

in  large  airy  rooms,  with  good  hygienic  surroundings;  thus  it  is  wise  to 
study  the  origin  of  tliis  disease  before  commencing  any  specific  treatment. 

The  largest  number  of  cases  are  seen  with  bottle-fed  babies.  It  is  here 
that  the  physician  will  be  called  upon  to  exercise  the  greatest  amount  of 
judgment.  Errors  in  feeding,  particularly  over-feeding,  and  giving  the 
infant  the  bottle  whenever  it  cries,  must  be  looked  upon  as  a  means  of 
aggravating  and  exciting  gastritis,  if  not  being  the  real  cause  of  the  dys- 
pepsia. 

Pathology. — The  mucous  membrane  of  the  stomach  is  always  swollen 
and  thickened.  Occasionally  erosions  and  haemorrhages  are  found.  The 
tissue  beneath  the  mucous  membrane,  the  submucosa,  will  be  found  oedema- 
tous.  The  interstitial  tissue  is  infiltrated  with  leucocytes  and  the  differentia- 
tion between  the  parietal  and  principal  cells  cannot  be  clearly  outlined. 
All  the  cells  appear  cloudy  and  granular  and  partially  separated  from  the 
membrana  propria  of  the  gland.  There  is  an  abundance  of  the  mucous 
colls  in  the  pyloric  region,  and  this  increase  extends  deeply  into  the  ducts 
of  the  glands. 

When  gastritis  is  met  with  in  older  children  the  origin  of  the  trouble 
can  easily  be  traced.  Over-eating,  especially  cakes  and  pies  and  puddings; 
too  rapid  chewiDg  and  swallowing  of  unmasticated  pieces  will  aggravate  an 
attack  of  this  kind. 

Gastritis  is  seen  more  often  in  older  children  who  are  permitted  to 
drink  wine  or  beer  at  the  table  with  their  parents.  It  is  quite  common  to 
have,  especially  among  the  working  classes,  distinct  evidences  of  alcoholic 
gastritis.  Children  are  permitted  to  take  a  drop  of  whisky  or  wine  or  beer, 
as  their  parents  say,  "to  strengthen  them." 

In  a  large  dispensary  service  with  which  the  writer  has  been  associated 
for  the  past  fifteen  years,  among  a  large  foreign  and  native-born  element, 
it  was  found  by  careful  questioning  that  more  than  50  per  cent,  of  the 
children  brought  to  this  service  were  permitted  to  use  stimulants. 

Unwholesome  feeding,  candies,  and  ice  creams  have  frequently  caused 
acute  gastritis  in  many  children. 

Symptoms. — A  young  infant  will  suddenly  refuse  to  take  its  bottle  and 
will  appear  very  peevish  and  thirsty,  flex  its  legs  on  its  abdomen,  will  seem 
dissatisfied,  and  refuse  to  play.  Vomiting  is  a  frequent  symptom.  The 
infant  will  cry  and  put  its  fingers  in  its  mouth.  The  temperature  on  the 
first  day  ranges  between  102°  and  103*  F.,  though  it  may  reach  as  high  as 
105°, F.  in  the  rectum.  The  pulse  ranges  between  140  and  160.  The  res- 
piration is  sometimes  accelerated.  The  tongue  is  usually  coated  with  a 
white  or  a  grayish-white  fur,  and  there  is  a  foetid  odor  to  the  breath.  Diar- 
rhoea may  be  present,  although  constipation  is  more  frequently  met  with. 

When  children  are  extremely  anaemic,  or  if  from  previous  malnutrition 
they  are  rachitic,  the  disease  will  commence  with  convulsions.    Convulsions 


244  DISEASES  OF  THE  STOMACH. 

must  not  be  looked  upon  as  very  serious  unless  they  recur  several  times 
during  the  first  day  of  the  attack. 

A  diagnosis  of  meningitis  will  frequently  be  made  in  the  commence- 
ment of  an  acute  catarrhal  gastritis,  unless  we  study  the  pulse-rate.  In 
meningitis  the  pulse-rate  is  usually  slow,  in  gastritis  it  is  greatly  accelerated. 
Pressure  on  the  epigastrium  will  show  marked  tenderness.  The  stomach 
is  usually  distended  and  tympanitic  on  percussion. 

If  a  child  is  old  enough  to  complain,  there  are  usually  subjective  symp- 
toms such  as  headache,  frontal  in  character,  and  pains  in  the  arms  and 
legs  will  be  described.  Jaundice  will  usually  be  found  in  older  children  in 
the  course  of  the  disease,  and  denotes  an  extension  of  the  catarrhal  inflam- 
mation from  the  stomach  into  the  duodenum,  thus  gastro-duodenitis  may 
be  diagnosed  when  jaundice  is  established. 

Prognosis  and  Course. — The  prognosis  of  an  acute  catarrhal  gastritis 
depends  on  the  time  of  the  year  and  the  condition  of  the  child  at  the  time 
of  the  attack.  If  a  bottle-fed  infant  is  attacked  with  gastritis  in  midsum- 
mer, and  it  cannot  be  removed  from  the  sultry  city,  then  the  prognosis  is 
grave.  If,  however,  breast-milk  can  be  given  judiciously  and  the  feeding 
interval  conform  with  the  requirements  of  the  weak  digestive  apparatus, 
then  we  may  reasonably  hope  for  a  favorable  termination.  If  complications 
occur,  chief  among  which  may  be  typhoid  fever,  or  an  extension  of  the 
disease  from  the  stomach  into  the  bowel,  then  the  outlook  will  not  be  good, 
unless  we  can  remove  the  patient  to  the  mountains  or  seashore. 

Nephritis  frequently  complicates  gastritis,  and  when  such  complica- 
tions exist  the  prognosis  is  bad.  Infectious  diseases  complicating  gastritis 
will  render  the  prognosis  unfavorable. 

The  important  point  to  note  is,  how  much  food  is  being  assimilated. 
If  the  infant  digests  a  proper  quantity  of  food  the  prognosis  is  good;  if, 
liowever,  vomiting  continues  and  we  cannot  feed  the  child  per  mouth  or 
per  rectum,  then  the  prognosis  is  very  grave.  We  must  aim  to  prevent 
starvation  if  the  child's  life  is  to  be  saved. 

Treatment. — The  first  thing  to  do  is  to  cleanse  the  stomach.  This  can 
be  accomplished  by  giving  a  dose  of  castor-oil,  syrup  of  rhubarb,  or  calomel. 
If  the  child  is  old  enough  some  citrate  of  magnesia  in  wineglassful  doses, 
repeated  every  two  or  three  hours,  will  correct  fermentation.  When  rapid 
cleansing  of  the  stomach  is  demanded,  owing  to  toxic  symptoms  from 
ptomaine  poisoning  or  from  other  poisons,  an  emetic  should  be  given.  A 
dose  of  1  grain  of  sulphate  of  copper  in  a  teaspoonful  of  water,  repeated 
every  half-hoilr  until  vomiting  is  produced,  will  materially  aid  in  cleansing 
the  stomach.  Syrup  of  ipecac,  in  teaspoonful  doses,  may  also  be  given  in 
some  instances,  although  the  writer  does  not  advocate  the  use  of  syrups  in 
acute  fermentative  diseases  of  the  stomach  or  bowels.  In  other  cases  wash- 
ing the  stomach  with  a  soft  catheter,  as  mentioned   in  the  treatment 


PLATE  XI 

(Original.) 


Fig.   I. 

Baby  P.,  one  year  old,  was  seen 
at  the  children's  service  of  the 
German  Poliklinik  during  the 
summer  months.  She  had  fever, 
anorexia,  and  intense  thirst. 
Vomiting  was  present;  the  bowels 
were  loose  and  contained  nuicus 
and  curds.  The  diagnosis  of  acute 
dyspepsia  ^^•as  made.  The  gastric 
content,  in  ichich  these  large 
curds  ivere  found,  teas  syplioned 
off  three  hours  after  feeding.  It 
was  evident  that  the  infant  could 
not  digest  whole  milk.  Equal 
parts  of  milk  and  rice-water  was 
ordered.  A  cleansing  dose  of  cas- 
tor-oil was  given. 


Fig.  II 


Fig.  Til. 

Gastric  contents  of  the  same  in- 
fant sy])lioned  of}'  three  hours  after 
feeding  with  e(|ual  parts  of  milk 
and  water  modified  by  the  addition 
of  four  teaspoonfuls  of  Eskay's 
Food.  The  cliaracter  and  size  of 
the  curd  are  worth  noting.  It 
illustrates  the  mechanical  effect 
produced  l)y  the  food  in  breaking 
up  the  curd. 


Pig.   I. 


Fig.  II. 

Two  days  later  the  infant  was 
again  seen.  The  symptoms  were 
greatly  improved.  The  vomiting 
was  stopped.  The  fever  was  less. 
Btomach-irasliing  was  again  re- 
sorted to  three  hours  after  the 
last  food  icas  taken.  A  pint  of 
warm  water,  to  wliich  a  teaspoon- 
ful  of  salt  had  been  added,  was 
used.  As  the  curd  was  but  par- 
tially digested  in  this  dilution  of 
food,  I  decided  to  add  an  infant 
food,  to  produce  mechanical  break- 
ing up  of  the  curd. 


Fig.  III. 


ACUTE  GASTRIC  CATARRH.  245 

of  summer  complaint,  will  prove  very  valuable.  Several  pints  of  table  salt 
solution  or  of  normal  salt  solution^  can  be  used  to  thoroughly  cleanse  the 
stomach  until  the  water  is  syphoned  off  quite  clear.  In  washing  the  stomach 
with  the  aid  of  a  soft  rubber  catheter  there  is  usually  quite  some  irritation 
produced  in  the  pharynx  and  oesophagus,  and  thus  vomiting  will  usually 
aid  in  the  lavage  in  clearing  the  stomach  of  its  contents.  When  such  treat- 
ment has  been  instituted  it  is  advisable  to  allow  the  stomach  to  rest  at  least 
six  or  seven  hours,  and  meanwhile  give  sterile  water — "ordinary  boiled 
water" — ad  libitum. 

When  the  bowels  have  been  properly  cleansed  and  the  stomach  has 
been  washed  by  lavage,  or  treated  with  one  of  the  above-mentioned  laxa- 
tives, then  the  after-treatment  will  consist  in  preventing  further  fermen- 
tation and  also  in  toning  up  the  patient's  condition. 

Medicinal  Treatment. — Experiments  have  shown  that  when  the  gastric 
contents  have  been  syphoned  off  or  examined  immediately  after  an  emetic 
has  been  given,  in  an  acute  gastritis,  that  there  is  a  deficiency  of  hydro- 
chloric acid.    This  is  an  indication  then  as  to  what  is  required. 

Diluted  hydrochloric  acid  given  in  doses  of  from  2  to  5  drops  has 
served  the  writer  very  well  when  given  every  three  or  four  hours. 

IJ  Acid  hydrochloric  dilut   1  drachm 

Essence  pepsin    (Fairchild.)    2  ounces 

M.  D.  S.  Teaspoonful  repeated  every  two  or  three  hours. 

Beta-naphthol  bismuth  in  doses  of  1  to  5  grains,  every  two  hours,  has 
served  me  very  well.  Calcined  magnesia^  is  also  very  valuable.  The  fol- 
lowing prescription  has  been  used  with  very  good  results  in  dyspeptic  con- 
ditions attended  with  constipation: — 

I^  Magnesia   usta 1  drachm 

Pulv.  rhei 1  drachm 

Saccharine     2  grains 

M.  and  divide  into  12  powders.  One  powder  to  be  given  in  a  teaspoonful  of 
sterile  water  every  two  or  three  hours. 

Powdered  charcoal  added  to  the  above  prescription  in  doses  of  1  grain 
three  times  a  day,  is  frequently  useful.  Salol  in  doses  of  1  grain  every  two 
or  three  hours,  and  resorcin  in  doses  of  */io  grain  or  '^/^  grain,  for  a  child 
1  year  old,  repeated  three  times  a  day,  will  do  good  in  some  instances. 

A  very  good  liquid  preparation  sold  in  drug  stores  is  milk  of  magnesia 
(Phillip's).  It  is  an  excellent  antacid  and  corrective  when  flatulence 
exists. 

^Formulae  for  saline  solutions  will  be  found  in  the  chapter  on  "Scarlet  Fever." 
'  Magnesia  in  powdered  form  I  frequently  use  is  known  as  Husband's  Magnesia 
in  drug  stores. 


246  DISEASES  OF  THE  STOMACH. 

When  severe  thirst  exists  boiled  water  may  be  given.  This  water  may 
be  acidulated  with  a  few  drops  of  diluted  phosphoric  acid,  and  will  be 
found  not  only  very  grateful  and  cooling,  but  very  serviceable  if  the  child 
has  a  tendency  to  diarrhoea  in  midsummer. 

Dietetic  Treatment. — The  most  important  point  to  remember  is  the 
feeding.  If  we  are  dealing  with  the  nursling,  then  breast-milk  should  be 
withheld  for  about  one-half  day.  When  the  breast  is  given  again,  the  infant 
should  not  be  permitted  to  nurse  more  than  two  or  three  minutes,  and 
immediately  after  taking  the  breast  the  infant  should  receive  3  or  4  ounces 
of  sweetened  rice  water.  In  this  manner  we  will  give  the  infant  diluted 
milk.  This  breast  and  rice  water  feeding  should  be  repeated  in  four  hours, 
no  sooner,  no  matter  what  the  age  of  the  infant. 

What  might  appear  very  radical  is  simply  advised,  to  prevent  the  stom- 
ach from  performing  its  usual  amount  of  work  until  the  gastric  function 
is  reestablished.  If,  however,  the  child's  appetite  warrants  it,  then  one  or 
two  days  should  elapse  before  giving  it  its  former  regular  quantity  of  nurs- 
ing. The  guide  to  the  return  of  the  normal  quantity  of  nursing  will  be  the 
divsappearance  of  tlie  fever  and  of  the  accelerated  pulse-rate.  The  child's 
craving  for  the  l)reast  can  be  noted  chiefly  by  constant  crying  when  the 
breast  is  removed,  and  tlie  ravenous  manner  in  which  it  nurses. 

In  bottle-fed  babies  it  is  advisable  to  give  the  child  one-half  of  the 
former  quantity  of  milk  or  cream  which  it  received  at  the  time  of  its  illness, 
and  if  it  is  found  that  the  sugar  contained  in  the  food  aggravates  this  con- 
dition, a  small  quantity  of  saccharine  may  be  used  to  sweeten  the  milk,  and 
the  sugar  discontinued.  Some  children  show  distinct  fermentative  changes 
after  the  use  of  too  much  sugar.  In  such  cases  the  use  of  saccharine  or  one- 
half  teaspoonful  of  glycerine  to  each  bottle  of  milk  is  sometimes  beneficial 
as  a  temporary  substitute. 

Glycerine  is  absolutely  harmless  and  may  be  given  for  months  with 
impunity.  My  rule  is  to  insist  on  the  use  of  sugar  if  at  all  possible.  Lime 
water  in  doses  of  a  teaspoonful  or  a  tablespoonful  may  be  added  to  the 
milk.  Five  grains  of  bicarbonate  of  soda  may  be  added  to  the  milk  or 
given  before  each  feeding.  If  vomiting  follows  the  milk-feeding,  whey 
should  be  substituted. 

Attention  must  be  paid  to  the  quality  of  milk  given  to  infants.  There 
are  many  dairies  in  New  York  City  which  furnish  an  excellent  quality  of  milk, 
owing  to  the  great  care  bestowed  upon  the  milk  supply  by  the  Health  De- 
partment, and  also  by  the  Milk  Commission. 

If  milk  seems  to  aggravate  an  attack  of  dyspepsia,  then  zoolak  or 
tumyss  or  other  fermented  milk  may  be  tried.  Buttermilk  is  very  nour- 
ishing and  very  useful  in  dyspepsia.  Junket  may  also  be  tried,  so  also  can 
whey  be  given  several  times  a  day.  Soups  and  broths,  calf's  foot  and  chicken 
jellies  are  all  nourishing.     Steak  juice  and  unfermented  grape  juice  will 


ACUTE  GASTRIC  CATARRH.  247 

be  servicable.  Boiled  fruits,  such  as  apples  and  peaches,  if  the  child  is  old 
enough  and  the  condition  warrants  it,  may  be  tried. 

Our  aim  must  be  to  have  the  infant  fed  with  a  large  interval  of  rest, 
60  that  nausea  and  vomiting  may  be  prevented,  and  in  order  that  the  food 
may  be  properly  assimilated.  We  must  therefore  give  small  quantities  with 
large  feeding  intervals.  When  the  functions  are  again  normal  then  we  can 
return  to  a  judicious,  nutritious  diet,  as  demanded  by  the  infantile  stomach. 
It  is  advisable  to  give  nux  vomica  in  doses  of  1  minim  for  a  child,  1  to.  3 
years  old,  three  times  a  day  before  feeding,  and  to  continue  the  same  for 
months  after  the  gastritis  disappears.  The  writer  has  seen  the  most  marked 
improvement  following  the  use  of  this  drug,  and  regards  it  as  a  specific  for 
toning  the  stomach. 

Malt  extract  should  be  given  in  doses  of  a  half  teaspoonful,  three  times 
a  day,  to  aid  nutrition.  It  is  well  known  that  malt  has  a  decided  laxative 
effect.  Care  should  be  taken  that  fermentation  is  not  reestablished  while 
giving  malt.  In  some  cases  it  is  not  well  borne  in  the  commencement  of  an 
acute  gastritis,  and  a  total  abstinence  of  milk  and  the  substitution  of  boiled 
water,  whey,  soups,  and  broths  may  become  necessary;  very  weak  tea,  to 
which  the  white  of  a  raw  egg  has  been  added  and  sweetened  with  saccharine 
or  with  granulated  sugar,  can  be  given  with  advantage. 

Fever. — The  temperature  in  the  course  of  an  acute  gastritis  requires 
no  antipyretic  treatment,  although  sponging  the  surface  or  a  cold  pack, 
applied  over  the  thorax  and  abdomen,  will  be  servicable.  Specific  fever 
treatment  is  uncalled  for.  The  well-known  depressing  effect  of  antipyretic 
drugs  must  not  be  forgotten,  and  hence  the  specific  cause  of  the  disease 
must  be  removed.  This  is  usually  stagnant  food.  The  same  requires  clean- 
ing out  with  calomel  or  cascara.  The  cause  of  the  fever  will  be  removed 
with  such  effectual  treatment. 

When  children  have  a  tendency  to  convulsions  then  a  mustard  foot- 
bath can  be  given  and  an  ice-bag  applied  over  the  anterior  fontanel,  or 
at  the  nape  of  the  neck.  In  such  instances  the  most  rapid  treatment  will 
be  called  for,  such  as  washing  the  stomach  with  a  catheter,  using  warm  salt 
water.  An  emetic  will  prove  useful  in  those  cases  where  lavage  cannot  be 
successfully  carried  out. 

Alcoholic  stimulation  is  contraindicated  in  every  form  of  gastric  fever. 
The  writer  has  always  seen  bad  results  follow  the  use  of  whisky  when  the 
gastric  mucous  membrane  was  inflamed.  If,  however,  the  patient  is  threat- 
ened with  collapse,  or  the  pulse  is  very  weak,  then  small  doses  of  musk  in 
tbe  form  of  a  tincture  of  musk  can  be  injected  hypodermically,  every  hour, 
until  the  pulse-rate  improves.  Camphorated  oil,  injected  hypodermically,  in 
doses  of  from  5  to  15  minims,  may  do  good  in  some  cases. 

Whisky  in  doses  of  5  to  15  minims,  hypodermically,  should  be  u?ed 
when  the  heart  sounds  are  feeble  and  the  pulse  is  thready.      If  violent 


248  DISEASES  OF  THE  STOMACH. 

vomiting  continues  champagne  can  be  given  per  mouth,  and  if  symptoms  of 
collaj^se  appear,  very  cokl  champagne  in  doses  of  a  leaspoouful,  repeated 
every  half-hour,  until  proper  elfects  are  obtained. 

Convalescence  will  de|)end  on  the  condition  of  the  patient  after  the 
attack,  and  it  is  advisable  to  remove  the  child  in  the  summer  to  the  sea- 
shore or  mountain  wliile  recuperating.  If  an  attack  appears  in  winter 
and  the  child's  vitality  is  subnonual,  then  a  change  to  a  milder  climate  in 
the  South  or  in  the  West,  from  the  city  to  the  country,  or  from  the  country 
to  the  city,  M-ill  frequently  restore  normal  functions.  Judicious  feeding 
will,  however,  be  the  most  potent  factor  in  tbe  future  development  of  the 
child. 

Spasm  of  the  Pylorus  (Spasmodic  Stenosis.) 

This  condition  is  obscure.  Some  clinicians  describe  congenital  stenosis 
due  to  a  In'pertrophy  of  the  pylorus.^ 

Pfaundler,  who  has  studied  this  subject  most  accurately,  believes  that 
the  symptoms  described  as  congenital  hypertrophic  stenosis  are  more  ap- 
parent than  real.  He  attributes  the  stenosis  to  a  spasm  of  the  pyloric 
sphincter.  An  important  point  bearing  on  the  possible  congenital  origin  of 
this  trouble  is  the  fact  that  the  symptoms  usually  commence  soon  after 
birth,  hence  the  presumption  of  a  congenital  origin  of  this  trouble-  seems 
plausible. 

Pritchard  has  reported  24:  cases  where  the  vomiting  Ijcgan  at  l)irth  or 
between  the  first  and  seventh  days. 

Symptoms  and  Diagnosis. — Persistent  vomiting  usually  during  the 
first  few  days  after  birth  or  as  late  as  the  fifth  week,  as  reported  l)y  Finkel- 
stein,^  is  one  of  the  earliest  symptoms. 

The  quantity  of  food  expelled  is  sometimes  far  greater  than  tbe  quan- 
tity swallowed  during  the  last  nursing  from  the  breast  or  bottle.  This  is 
evidently  due  to  retention  of  the  previous  meal,  and  has  an  important  bear- 
ing on  the  diagnosis  of  stenosis. 

There  is  no  milk  residue  in  the  stool,  simply  a  mucous  or  gelatinous 
(green-bilious)  stool,  which  excludes  ol)struction  below  the  duodenum. 
These  symptoms  continue  until  tliere  is  a  sudden  stoppage  of  tlie  vomiting. 
With  the  disa])pearance  of  the  vomiting  digested  milk  can  be  noticed  in  the 
stools.  In  some  cases  a  tumor  can  be  palpated  at  the  region  of. the  pylorus. 
There  may  also  l>e  dilatation  of  the  stonmch  with  visible  jieristaltic  move- 
ments. In  some  instances  emaciation  due  to  inanition  will  be  noted.  The 
temperature  of  the  child  is  not  affected.  For  treatment,  read  article  on 
Hypertrophic   Pyloric   Stenosis. 


^  Southworth,  Arcliivos  of  Pediatrics,  .Taiiuary.  1901. 
-  Jahr.  f.  Kinderh.,  vol.  xviii.  p.  105. 


HYPERTROPHIC  PYLORIC  STENOSIS.  249 

HYPERTKoriiic  Pylokic  Stenosis. 

This  condition  is  not  so  rare  in  infanc}^  as  is  commonly  supposed. 
While  in  1902  Cautle}'  and  Dent  reported  109  cases,  we  have  since  then 
over  150  cases  recorded  in  medical  literature. 

In    our    own    comitry,    Pritchard's,     Saunder's,    West's,    Dorning's, 
Meltzer's,  and  my  own  case  have  been  reported.     In  these  cases  an  operation  . 
for  the  relief  of  the  stenosis  or  a  post-mortem  proved  the  correctness  of  the 
diagnosis. 

Etiology. — Stenosis  may  occur  as  a  congenital  malformation.  Hyper- 
acidity is  believed  to  be  responsible  for  some  cases  of  spasm  of  the  pylorus 
resulting  in  hypertrophy.  Thomson  believes  that  by  the  ingestion  of  liquor 
amnii  in  intra-uterine  life  both  the  stomach  and  pylorus  are  excited  to  over- 
action,  due  to  the  presence  of  this  irritant  fluid. 

Morbid  Anatomy. — Under  normal  conditions  the  circular  muscle  fibers 
of  the  pylorus  at  Irirth  are  relatively  augmented,  gTadually  approaching  the 
normal  as  the  long  axis  of  the  stomach  assumes  its  horizontal  direction  from 
the  vertical ;  this  relative  augmentation  of  the  circular  fibers  is  intended 
to  prevent  the  too  rapid  emptying  of  the  vertical  tubular  infantile  stomach 
during  the  first  two  weeks  of  life.  These  fibers,  stimulated  to  excessive 
function  by  any  given  cause,  must,  according  to  recognized  physiological 
principles,  Ijecome  hypertrophied. 

Accepting  such  a  working  basis,  we  should  recognize  in  hypertrophic 
pyloric  stenosis  the  ultimate  results  of  a  pathological  process  whose  first 
stage  is  represented  by  an  excessive  fimctional  activity  of  the  pyloric  muscu- 
lature;  its  second  stage  l)y  hypertrophy  and  spasm  of  this  musculature,  and 
the  third  stage  by  a  general  overgrowth  of  the  normal  constituents  of  the 
involved  ])arts. 

Symptoms. — Soon  after  birth,  or  within  a  few  weeks,  there  is  a  sudden 
onset  of  symptoms.  'J'he  food  will  suddenly  disagree  and  the  infant  will 
vom't.  Vomiting  will  continue  whether  the  infant  is  nursed  at  the  human 
breast  or  artificially  fed.  The  vomiting  is  regurgitant:  at  times,  however, 
markedly  explosive.  The  quantity  vomited  ranges  from  a  teaspoonful  to 
many  ounces.  Bile  is  seldom  mixed  with  the  vomit.  As  a  rule,  the  vomit- 
ing has  a  very  sour  smell,  resembling  butyric  acid.  Large  strings  of  mucus 
of  a  glairy  character  and  sometimes  cheesy  curds  are  found  in  the  vomit. 

Owing  to  the  stenosis  of  the  pylorus,  no  food  passes  into  the  duodenum, 
hence  the  stool  will  be  found  to  contain  no  particles  of  milk  fa?ces.  If 
there  is  any  stool,  it  consists  of  a  mucus  mass,  usually  greenish  in  color.   . 

There  are  active  peristaltic  and  antiperistaltic  waves  visible.  This  is 
most  marked  after  the  infant  has  swallowed  food  or  water.  In  a  case 
reported  by  mo^  very  strong  peristaltic  waves  could  be  noticed  from  left  to 


'Arc'liivcs  of  IVdiiilrics.  'Mav.  lOOG. 


250  DISEASES  OF  THE  STOMACH. 

right.  There  was  a  distinct  hourghiss  contraction,  the  stomach  bulging 
on  either  side  with  a  sulcus  in  the  middle.  The  abdominal  walls  are  lax. 
The  intestinal  wall,  chiefly  the  transverse  colon,  can  be  easily  mapped  out. 

On  pal])ating  the  pylorus  in  my  own  case,  a  hard,  resisting  mass,  about 
the  size  of  an  adult's  thumb  could  be  felt.  Gradual  emaciation  from  inani- 
tion will  be  noted. 

Stagnation  of  the  gastric  contents  is  proven  by  the  fact  that  while 
two  ounces  of  the  food  is  swallowed,  six  or  eight  ounces  is  frequently  regur- 
gitated and  vomited.  The  quantity  of  urine  is  also  scant,  owing  to  the 
small  qiuuitity  of  liquid  and  food  absorbed.  A  whole  day  will  frequently' 
pass  without  a  siiigle  diaper  being  wet. 

The  examination  of  the  gastric  contents  shows  great  variability.  In 
my  own  case,  the  presence  of  lactic  acid  and  the  total  absence  of  hydro- 
chloric acid  was  noted.  Other  observers  have  noted  an  excess  of  hydro- 
chloric acid. 

Prognosis. — If  the  vomiting  persists,  death  will  occur  from  exhaustion. 
In  a  case  seen  by  me.  where  operation  was  refused,  the  infant  died  of  inani- 
tion after  three  weeks. 

Treatment. — Dilute  the  food  to  half-strength.  If  a  milk  mixture  con- 
taining 2  per  cent,  of  fat  has  been  given,  then  1  per  cent,  of  fat  should  be 
tried. 

There  should  be  a  longer  interval  between  the  feedings.  If  a  baby 
has  been  fed  every  two  hours,  it  should  be  fed  once  in  three  hours.  If  two 
ounces  had  been  given  at  one  feeding,  then  one  oimce  should  be  tried.  If, 
after  this  method,  vomiting  persists,  then  the  stomach  should  l)e  allowed  to 
rest  at  least  twenty-four  hours,  during  which  time  rectal  feeding  can  be 
tried.  Stomach-washing  every  morning  with  normal  saline  solution  may  do 
good  in  some  cases. 

On  the  theory  that  hyperacidity  Avas  the  cause  of  pyloric  spasm, 
Knoepfelmaclier  used  Avhole  milk  feedings  in  order  to  modify  the  hyper- 
acidity. Bromide  of  sodium,  codeine,  menthol,  or  subnitrate  of  bismuth 
may  be  tried. 

Surgical  Tieaimcnt. — If,  after  a  patient  trial  of  the  above-outlined 
plan,  the  condition  does  not  improve,  then  surgical  relief  is  indicated.  In 
this  stenotic  stage,  gastro-duodenostomy  in  two  sittings,  if  necessary,  should 
be  the  operation  of  choice. 

"At  the  first  of  these,  slight  fixation  of  the  involved  parts  to  the  abdomi- 
nal incision,  opening  of  the  duodenum,  and  the  insertion  of  a  temporary 
catheter  for  purposes  of  direct  feeding. 

"xVfter  a  proper  interval,  depending  upon  tlie  ])atient's  gain  in  nutrition 
and  strength,  an  anastomosis  between  this  opening  in  the  duodenum  and 
the  stomach,  either  by  the  small  ])utton  of  Meyer  or  a  modification  of  the 
Finney  operation."      (Sturmdorf.) 


CHRONIC  GASTRITIS.  251 

Post-operative  Treatment. — Strychnine,  Viso  gi'aJn  hypodennically 
every  three  hours,  is  required.  Normal  saline  injections,  either  by  high 
colonic  flushing,^  or,  if  the  pulse  is  weak,  by  means  of  hypodermoclysis. 

By  mouth,  several  teaspoonfuls  of  whey  every  hour.  This  method  is 
ample  for  the  first  few  days,  after  which  special  feeding  rules  may  be  in- 
dicated. 

Gastro-duodenitis   (Catarrhal  Jaundice). 

When  the  infection  of  an  acute  catarrhal  gastritis  extends  into  the  duo- 
denum, jaundice  usually  results.  This  is  due  to  an  involvement  of  the 
common  bile  ducts. 

Symptoms  and  Diagnosis. — Yellowish  pigmentation  of  the  skin  and  con- 
junctival mucous  membrane  are  noted.  The  urine  is  brown  or  deep  yellow. 
The  stool  is  whitish  or  clay-colored.  The  temperature  ranges  between 
100°  and  103°  F.  Anorexia  and  thirst  usually  exist.  Nausea  or  vomiting 
may  occur.    The  pulse  is  full  and  regular.    The  liver  is  usually  enlarged. 

Treatment. — Elaterine  or  podophylliu  in  14  grain  doses,  repeated,  if 
necessary,  in  three  hours,  or  phosphate  of  soda,  10  to  20  grain  doses  every 
three  hours,  until  liquid  stools  are  produced.  Dilute  nitro-muriatic  acid, 
2  to  5  drops  may  be  given  twice  a  day.  Liquid  food,  such  as  thin  soups, 
diluted  milk  or  skim-milk  or  buttermilk,  and  fruit  juices,  for  thirst. 

Chronic  Gastritis  (Chronic  Glandular  Gastritis — Chronic 

Vomiting). 

This  is  a  chronic  inflammatory  disease  affecting  the  gastric  mucous 
membrane.  The  functions  of  the  stomach  are  disturbed  owing  to  the  large 
quantities  of  alkaline  mucus  being  secreted.  There  is  a  distinct  loss  of 
tone  in  the  gastric  mucosa.  Large  quantities  of  food  will  frequently  stag- 
nate, causing  fermentation  and  vomiting. 

Pathology.— The  changes  in  chronic  gastritis,  seen  post-mortem,  are 
similar  to  those  mot  with  in  the  acute  form.  There  is  a  degeneration  of  the 
epithelium  of  the  gastric  tubules.  Frequently  there  is  dilatation  of  the 
stomach. 

^licroscopically  the  glands  often  seem  enlarged,  sacculated,  and  dilated 
in  cyst-like  fonns.  Ewald  states  that  there  is  a  mucoid  degeneration. 
When  there  is  a  total  destruction  of  the  glandular  layer  of  the  entire  organ, 
we  have  an  atrophic  condition  wliich  EwakI  calls  anadenia  voiitriculi. 

Symptoms. — Vomiting  is  a  prominent  sympiom.  Large  quantities  of 
sour  oi-  l)ilo-stained  mucus  are  ejected.  At  otlier  times  sour-smelling  liquid 
containing  particles  of  food  is  ejected.  Farinaceous  foods  cause  particular 
distress.  Pains  referred  to  the  abdomen  are  complained  of,  and  the  abdo- 
men is  usunllv  distended  and  tender  on  palpation.      The  tongue  is  coated. 


252  DISEASES  OF  THE  STOMACH. 

The  papillae  are  enlarged  and  the  edges  and  tip  are  of  a  bright  glazed  red. 
Eructations  of  gas  are  frequently  noted,  especially  after  feeding. 

The  Bowels. — Constipation  alternates  with  diarrhoea  in  this  condition. 
We  find  a  child  will  sufEer  with  constipation  for  three  or  four  days,  and  for 
no  apparent  reason  a  diarrhoea  will  appear  and  continue  for  a  week  or 
more.  Eczema  is  usually  associated  with  this  condition.  There  is  usually 
anorexia.  Owing  to  the  malnutrition  such  children  appear  underfed  and 
seem  to  be  anaBmic.  They  emaciate  from  loss  of  sleep  in  addition  to  the 
continued  vomiting.  Their  extremities  are  usually  cold,  owing  to  a  poor 
circulation.  Headache  is  a  prominent  symptom  in  children  old  enough  to 
complain.  The  clinical  picture  is  such  that  one  must  take  extreme  care 
to  make  a  proper  diagnosis.  Frequently  there  is  a  hacking  cough  present. 
We  may  exclude  tuberculosis  if  the  pulmonary  signs  are  wanting  in  addi- 
tion to  the  absence  of  the  tubercle  bacillus. 

Diagfnosis. — The  diagnosis  is  easily  made  if  we  remember  that  tuber- 
culosis has  fever  which  at  times  assumes  a  hectic  form.  We  have  previously 
mentioned  the  necessity  of  finding  the  tubercle  bacillus  if  tuberculosis  is 
suspected.  Typhoid  fever  is  so  different  that  we  can  easily  exclude  this  by 
resorting  to  the  Widal  and  diazo  reactions.  Syphilis,  if  suspected,  will 
respond  to  specific  treatment. 

Prognosis  and  Course. — This  condition  should  be  looked  upon  as  every 
other  chronic  disease  in  which  vitality,  surroundings,  and  proper  care  play 
an  important  part.  If  a  child  of  a  poor  family  living  in  a  tenement  house 
suffers  with  this  chronic  disease,  the  outcome  will  be  different  than  if  the 
child  were  living  in  the  country  where  fresh  air  could  and  would  stimulate 
metabolism.  Earely  is  this  condition  fatal,  although  with  extreme  emiacia- 
tion  and  continued  vomiting  inanition  may  cause  death. 

Treatment. — Dietetic  Treatment:  This  is  the  most  important  factor. 
The  feedinor  interval  should  be  extended  so  that  the  child  should  be  fed 
less  often  than  formerly.  The  quantity  of  food  should  be  reduced  so  that 
the  stomach  receives  less  work.  By  all  means  give  food  that  is  easily  as- 
similated. In  some  cases  nothing  but  predigested  food  or  peptonized  milk 
will  be  retained.  Each  child  should  receive  a  carefully  prepared  diet  list, 
and  we  must  insist  on  strict  rules.  Give  older  children  soups,  broths,  albu- 
min, such  as  white  of  egg,  and  peptonized  yolk  of  Qgg.  Give  infants  diluted 
milk  or  one  of  the  infant  foods  temporarily.  When  vomiting  persists  and 
apparently  little  or  no  food  is  retained,  it  is  advisable  to  put  the  child  to 
bed  and  resort  to  rectal  feeding  for  two  or  three  days.  This  is  one  of 
the  best  means  of  allaying  gastric  irritability.  (See  chapter  on  "Eectal 
Feeding.") 

Hygiene.  —  Without  fresh  air,  active  exercise,  such  as  walking,  or 
passive  movements,  such  as  massage  or  gymnastics,  we  must  expect  little 
or  no  benefit.  Daily  sponging  or  bathing,  followed  by  friction  with  a  coarse 
towel,  will  stimulate  the  circulation. 


ACUTE  DILATATION  OF  THE  STOMACH. 


253 


Medication. — Stomach  washing,  by  using  1  or  2  pints  of  warm  water 
to  which  bicarbonate  of  soda  has  been  added,  is  very  useful.  This  may  be 
repeated  every  day.  Sodium  phosphate,  in  5  to  10-grain.  doses,  every  morn- 
ing or  evening,  is  indicated. 

Fowler's  solution,  in  1  to  5-drop  doses,  three  times  a  day,  and  nux  vomica, 
in  1-minim  doses,  three  times  a  day.^ 

Bismuth  subnitrate  or  bismuth  beta-naphthol  to  relieve  the  diarrhoea, 
are  very  valuable  remedies. 

For  persistent  vomiting  menthol  in  1-grain  doses,  and  oxalate  of  cerium, 
in  2  or  3 -grain  doses,  every  few  hours,  is  useful.  Gentle  currents  of  faradic 
electricity  will  also  aid  and  strengthen  the  atonic  condition. 

Acute  Dilatation"  of  the  Stomach. 

This  condition  is  quite  frequently  met  with  in  children. 
Etiology. — The  anatomical  and  physiological  peculiarities  of  tbe  in- 
fantile stomach  render  it  peculiarly  susceptible  to  the  development  of  this 


DILATED  STOMACH. 
iAt  age  of  one. month. 


Fig.  68.— Drawing  from  a  Case  of  Acute  Dilatation  of  the  Stomach, 
Giving  Exact  Size  Post-mortem.  Bottle-fed  Infant.  Summer  Complaint, 
Due  to  Over-feeding,  and  Too  Frequent  Feeding.  Compare  normal  size  witli 
the  dilated  condition.     (Oiiginal.) 


'  Fraser,  of  New  York  City,  makes  a   1-niinim  nux  vomica   tablet,  whicii  is 
soluble  and  quite  palatable. 


254  DISEASES  OF  TIIE  STOMACH. 

condition.  The  walls  of  the  stomach  are  thin.  The  weakness  of  the  re- 
sistance of  the  muscular  walls  and  the  ease  with  which  a  general  anaemia 
and  resultant  muscular  atony  occurs  in  children  must  be  remembered  in 
considering  etiological  factors.  Eachitis  plays  an  important  part  in  the 
development  of  this  condition.  Severe  gastric  catarrh  with  associated 
fermentative  conditions  are  predisposing  factors. 

Pathology. — A  general  atrophied  condition  of  the  entire  gastric  wall 
exists.  The  muscular  coats  are  frequently  thickened.  The  mucous  mem- 
brane shows  evidences  of  chronic  catarrh.  This  condition  is  usually  seen 
in  marasmic  or  rachitic  children.    The  stomach  is  invariably  dilated. 

The  symptoms  of  this  condition  correspond  to  those  of  chronic  gastric 
catarrh.  In  standing  the  child  upright  the  contour  of  the  greater  curvature 
of  the  stomach  can  be  made  out  if  emaciation  exists.  Vomiting  is  a  promi- 
nent symptom,  a  sour,  frothy  liquid  being  thrown  up.  Succussion  is  fre- 
quently heard,  but  cannot  be  depended  on  as  a  positive  symptom  in  this 
condition.  Children  suffering  with  acute  dilatation  usually  have  a  very 
good  appetite.  They  always  show  evidences  of  malnutrition.  The  results 
of  percussion  are  very  misleading.  A  tympanitic  sound  may  be  heard  when 
the  child  is  on  its  back.  It  may  also  be  absent.  Henoch  states  that  severe 
dilatation  of  the  stomach  in  a  child  may  cause  dyspnoea.  It  may  also  dis- 
place the  heart  if  dilatation  is  severe. 

Diagnosis. — The  diagnosis  can  usually  be  made  by  the  symptoms  above 
described.  It  is  important  to  remember  that  a  dilatation  of  the  colon  may 
exist  at  the  same  time;  if  so  the  differentiation  between  dilatation  of  the 
colon  and  dilatation  of  the  stomach  can  be  made  by  artificially  distending 
the  stomach  with  the  aid  of  a  Seidlitz  powder.  Translumination  of  the 
stomach  with  the  aid  of  a  gastrodiaphane  will  aid  in  mapping  out  the 
anatomical  outlines  of  the  stomach. 

Prognosis. — This  depends  on  the  condition  of  the  child  when  treat- 
ment is  commenced.  If  the  child  is  physically  debilitated  and  does  not 
assimilate  food,  the  prognosis  is  grave.  It  is  safest  to  give  a  cautious 
prognosis  in  every  case. 

Treatment. — Semi-solid  foods  should  be  given,  if  possible,  and  large 
quantities  of  liquids  avoided.  The  normal  tone  of  the  stomach  can  best  be 
restored  by  the  administration  of  nux  vomica  and  iron  in  suitable  doses. 
The  value  of  electricity  and  massage  must  be  remembered.  They  will 
restore  the  tone  of  the  stomach  when  judiciously  used.  Specific  conditions 
such  as  rickets  and  syphilis,  if  present,  require  their  proper  treatment 

Bulimia  (Abnormal  Appetite). 

Constant  desire  to  eat  is  frequently  seen  when  intestinal  parasites,  such 
as  tapeworm,  are  present.    It  is  also  found  as  a  symptom  of  hysteria. 


GASTROPTOSIS. 


255 


A.  B.,  7  3'ears  old,  desired  five  and  six  meals  a  day.  Her  body  was  emaciated 
and  occasional  abdominal  pains  were  described.  The  mother  attributed  the  pains  to 
overeating.  After  several  doses  of  filix  mas  a  tapeworm  was  dislodged  (see  treat- 
ment in  the  chapter  on  "Tapeworm")  and  the  bulimia  disappeared. 

Gastroptosis    (Descexsus  Ventriculi),  Low   Position   of 
THE  Stomach. 
We  are  indebted  to  Glenard^  for  emphasizing  sufficiently  the  clinical 
symptoms  due  to  this  condition. 

Etiology.^ — In  subnormal  conditions  such  as  chlorosis  or  where  a  gen- 
eral atony  exists,  a  weakening  of  the  ligaments  takes  place  and  the  abdora- 


Fig.  G7. — Translumination  of  the  Stomach  with  the  aid  of  a  Gastrodiapliane, 
in  a  case  of  Ciastroptosis.      (Original.) 

inal  viscera  consequently  descends.  Very  tight  lacing  is  frequently  a  cause 
in  young  girls. 

In  a  series  of  autopsies  made  by  Glenard  he  found  the  transverse  colon 
displaced  and  stcnosed.^ 

Symptoms. — A  variety  of  nervous  symptoms  such  as  irritability,  head- 
ache, restlessness  by  day  and  insomnia  by  night,  is  frequently  due  to  this 
disorder.  The  symptoms  which  characterize  nervous  dyspepsia  in  the  adult 
correspond  with  the  train  of  symptoms  noted  in  this  condition.  Constipa- 
tion is  usually  present;   there  is  loss  of  appetite  and  eructations. 


»Lyon  Medicale,  1885,  p.  450. 

•Einhorn:     "Diseases  of  the  Stomach."     First  Edition,  p.  368. 


256 


DISEASES  OF  THE  STOMACH. 


Dia^osis. — Ewald  advises  inflation  of  the  stomach  as  the  best  means 
of  diagnosis.  "When  the  stomach  is  inflated  the  lesser  curvature,  in  cases 
of  gastroptosis,  is  visible  midway  between  the  ensiform  process  and  the 
navel,  or  just  in  the  neighborhood  of  the  umbilicus."  With  the  aid  of  the 
gastrodiaphane  we  can  transluminate  the  stomach  and  make  out  the  contour 
of  the  same.  This  has  been  found  a  valuable  means  of  diagnosis.  The  red 
illuminated  area  can  be  plainly  made  out  if  the  room  is  darkened.  The 
following  case  illustrates  this  condition  as  met  with  in  practice: — 

Rosie  B.  was  first  seen  by  me  when  13  years  old. 

Family  Eistory. — Father  and  mother  living  and  well.  She  has  six  sisters  and 
one  brother  living,  all  in  good  health.  There  is  no  family  history  of  syphilis,  rheuma- 
tism or  tuberculosis.    One  child  of  3  years  died  from  pneumonia  complicating  me  isles. 

Personal  History. — She  was  a  breast-fed  child  and  appeared  to  be  well  de- 
veloped. She  has  had  measles  and  with  it  bronchitis.  Menstruation  appeared  when 
she  was  13  years  old  and  lasted  seven  days.     She  has  complained  for  the  last  two 


Fig.  fiS. —  (a)  Normal  Position  of  Stomach,     (ft)   Position  of  Stomach  in  a 
Case  of  Gastroptosis.      (Original.) 

years  of  headaches,  pains  in  the  back  and  abdomen,  loss  of  appetite,  and  does  not 
sleep  well.  She  is  very  nervoiis  and  has  had  a  peculiar  unilateral  twitching  in- 
volving the  right  arm  and  shoulder.  This  twitching  appears  spasmodically  and  is 
exaggerated  when  her  attention  is  directed  to  it.  She  complains  of  cold  extremi- 
ties, and  has  an  occasional  cough.  No  expectoration.  The  cough  appears  to  be 
of  the  same  character  as  that  seen  in  adults  which  is  described  as  a  hysterical  cough. 
The  chemical  examination  *  of  the  gastric  contents  syphoned  off  one  hour  after 
feeding  a  test  meal  of  tea  and  zwieback,  gave  the  following:  25  cubic  centimeters 
obtained,  color  greenish  yellow,  very  tenacious,  ptyalin  present  in  saliva.  Reaction 
of  gastric  juice  acid,  no  free  hydrochloric  present,  lactic  acid  absent,  peptones 
present,  sugar  present,  starch  present,  combined  hydrochloric  acid  present,  estimated 
by  titration  equals  .02  per  cent,  hydrochloric  acid.  A  splashing  sound  could  be  made 
out  on  the  left  side  of  the  abdomen  in  the  area  bounded  by  the  umbilicus  or  above 
it  to  the  symphysis  pubis.  With  the  aid  of  the  gastrodiaphane  the  outline  of  the 
stomach  could  be  plainly  seen  extending  below  the  umbilicus.  In  the  accompany- 
ing illustration  (Fig.  68)  the  position  of  the  stomach  is  outlined. 

» I  am  indebted  to  Mr.  La  Wall,  chemist,  for  this  analysis. 


ULCER  OF  THE  STOilACH.  257 

Prognosis  and  Course. — A  displaced  organ  is  not  easily  replaced  by 
giving  drugs  or  by  mechanical  treatment.  The  physician  should  inform 
the  patient's  relatives  regarding  the  true  condition.  The  life  of  the  child 
is  not  necessarily  endangered  by  the  displaced  stomach,  yet  the  abnormality 
should  be  treated  on  the  principle  of  general  building  up  of  the  entire  sys- 
tem with  special  reference  to  the  diet. 

Treatment. — The  treatment  of  these  cases  consists  in  building  up  tlie 
system  with  the  aid  of  electricity,  massage,  and  general  restorative  treat- 
ment; cold  sponging  with  brisk  friction  of  the  surface  of  the  body  to 
stimulate  the  circulation;  also,  light  bodily  gymnastics.  Nux  vomica  or 
its  alkaloid,  strychnine,  should  be  given  for  a  long  time. 

A  tight  fitting  abdominal  l)andage  has  frequently  relieved  acute  symp- 
toms. Boas,  of  Berlin;  Einhorn,  Kemp,  and  Iiose,  of  New  York,  are 
aiiiong  those  who  advocate  supporting  the  abdominal  muscles  by  this 
mechanical  device. 

Surgical  Treatment. — When  no  relief  is  obtained  by  the  abdominal 
-upporter  or  bandage  previously  referred  to,  then  surgery  may  be  demanded. 
Some  surgeons  advise  supporting  the  stonuich  by  means  of  stitching  the 
omentum  to  the  abdominal  peritoneum.  By  this  means  we  have  "a  method 
uf  suspending  the  stomach  in  a  hammock  made  by  the  great  omentuin."' 

Ulcer  of  the  Stomach. 

Gastric  ulcer  is  frequently  seen  in  chlorotic  girls.  It  is  usually  the 
result  of  living  in  unsanitary  surroundings,  or  when  the  body  is  reduced 
to  a  sul)normal  condition.  Young  girls  at  or  about  the  period  of  menstrua- 
tion that  are  sent  to  work  in  factories  or  shops,  who  cannot  take  proper 
time  for  their  meals,  are  occasionally  seen  with  evidences  of  gastric  ulcer. 
1)1  most  cases  the  ulcer  is  simply  a  continuation  of  a  chronic  catarrh  of  the 
-astric  mucous  membrane  which  has  laid  the  foundation  for  this  condition. 

Symptoms. — Pain  in  the  stomach  which  is  distinctly  localized  and  can 
bo  poinicd  to  in  the  same  area.  The  i)a!n  increases  after  taking  solid  food, 
although  ])ain  is  also  noted  when  any  liquid  enters  the  stomach.  At  times 
I)riglit  re(l  l)!ood  will  be  expectorated,  although  the  blood  may  be  very  dark 
in  color.  There  is  also  a  tender  area  usually  localized  between  the  ninth 
and  tenth  dorsal  vertebra  which  is  marked  on  palpation. 

Diagnosis. — The  positive  diagnosis  should  only  be  made  after  a  chem- 
ical examination  of  the  gastric  contents  is  made.  The  test  meal  and  the 
ineth.od  of  examination  is  descrilied  in  Part  XII,  page  915  to  which  the 
reader  is  referred.  If  an  excess  of  II CI  is  foimd  in  addition  to  the  sub- 
jective symptoms  of  pain,  the  diagnosis  of  gastric  tiIccm*  is  ])()si(ive. 

The  following  case  of  gastric  ulcer  was  presenled  by  me  liel'ore  the 
Xew   York   County   Medical   Association.    May    l-"),   l'6\)\) : — • 


258  DISEASES  OF  THE  STOMACH. 

Mary  B.,  13  years  old,  complained  of  headaches  and  general  weakness.  She 
was  emaciated  and  had  anorexia.  She  had  suffered  with  constipation,  dizziness, 
nausea,  and  vomiting.  Her  heart's  action  was  irregular.  For  four  years  she 
complained  of  pain  in  the  middle  of  the  stomach  which  was  always  localized  in 
the  same  area.  The  gastric  pains  were  strongest  after  partaking  of  solid  food. 
She  had  pain  whenever  any  food,  solid  or  liquid,  was  swallowed.  The  pain  is 
described  as  a  burning  pain.  She  has  a  tender  area  between  the  ninth  and  tenth 
dorsal  vertebr£E.  This  tenderness  is  marked  on  palpation.  Three  years  ago  she 
had  an  attack  of  haematamesis,  but  none  since  then.  Tlie  gastric  contents  were 
examined  after  a  test  meal,  and  an  excess  of  IlCl  was  found.  Owing  to  the 
danger  of  traumatism  I  thought  it  best  not  to  repeat  the  syphoning  off  of  the 
gastric  contents,  as  there  was  a  risk  in  repeating  the  hsemorrhage.  There  was  no 
evidence  of  hysteria  in  the  case.     The  diagnosis  of  gastric  ulcer  was  made. 

Treatment. — Liquid  diet,  rest  in  bed,  and  bismuth  gave  quite  some  relief. 
When  solid  food  was  tried  the  gastric  pain  returned. 

Prognosis  and  Course. — Great  care  should  be  taken  before  giving  a 
positive  opinion  concerning  the  outcome  of  gastric  ulcer.  If  the  condi- 
tions that  induced  the  disease  can  be  modified,  then  a  chance  for  recovery 
exists.  These  cases,  as  a  rule,  do  badly  unless  placed  under  the  strictest 
supervision  of  a  trained  nurse.  Such  cases  require  treatment  in  bed,  rather 
than  ambulant  treatment.  Years  of  patient  treatment  may  be  required 
before  positive  benefit  is  secured. 

The  prognosis  depends  on  the  above  conditions.  The  disease  is  chronic 
and  may  cause  death. 

Treatment. — Such  cases  do  well  by  having  a  change  of  air.  These 
children  should  not  be  permitted  to  attend  school,  and  the  same  applies  to 
the  workshop,  if  the  child  is  working.  Sea  bathing  and  cold  sponging  of 
the  body,  followed  by  friction,  is  very  beneficial.  A  rigid  liquid  diet,  con- 
sisting of  peptonized  milk,  zoolak,  soup,  broth,  and  strained  gruel,  with  an 
occasional  change  to  cocoa,  should  be  allowed.  Fruit  may  also  be  permitted. 
This  treatment  must  usually  be  carried  out  for  months  before  recovery  may 
be  expected. 

Ctclio  Vomitino. 

A  great  many  writers  report  attacks  of  vomiting  occurring  at  irregular 
or  regular  intervals  of  weeks  or  months  which  is  termed  cyclic  vomiting. 
They  claim  that  these  attacks  are  not  dependent  on  acute  gastric  disturb- 
ances, but  are  simply  explosives  due  to  latent  or  possibly  nervous  conditions. 
1  cannot  agree  to  the  above  statement,  as  in  all  cases  seen  by  me  in  which 
recurring  vomiting  took  place,  I  could  always  trace  some  dietetic  error  or 
some  auto-intoxication  as  an  exciting  factor  of  the  vomiting.  Joseph  Win- 
ters, an  authority  on  pediatrics,  ridicules  the  above  condition. 


DYSPEPTIC  ASTHMA.  259 


Dyspeptic  Asthma. 

Peripheral  irritation  of  the  terminal  filaments  of  the  pneumogastric 
nerve  frequently  causes  dyspeptic  symptoms  which  result  in  asthmatic 
attacks  similar  to  those  found  in  adults.  A  case  of  this  kind  came  under 
my  care  in  which  fermentative  conditions  in  the  stomach  caused  pressure 
on  the  diaphragm  and  gave  rise  to  asthmatic  attacks. 

A  well-nourished  boy,  9  years  old,  was  referred  to  me  by  Dr.  H.  Jarecky.  llo 
had  attacks  of  coughing,  wheezing,  and  slight  cyanosis.  The  hands  and  feet  were 
cold.  Tlie  tongue  was  coated,  the  stomach  distended  with  gas  and  A'ery  tympaniti  • 
on  percussion.  Tlie  asthmatic  attacks  were  caused  by  the  distention  and  pressure 
on  the  diaphragm,  and  disappeared  when  a  rigid  diet  and  a  laxative  was  given. 
The  boy  suffered  in  addition  with  rheumatism. 


CHAPTER  TV. 

DISEASES  OF  THE  INTESTINES. 

The  Abdomen. 

The  abdomon  of  a  child  is  comparatively  larger  than  that  of  the  adult. 
Especial  attention  should  be  given  to  the  condition  of  the  abdomen;  for 
instance,  a  retracted  a))domcn  is  usually  seen  in  meningitis.  (See  chapter 
on  "Meningitis.")  A  distended  alKloiuen  is  frequently  seen  in  rachitis 
(pot-belly).  (See  chapter  on  "Rachitis.'*)  A  very  prominent  abdomen  is 
seen  in  clironic  peritonitis,  to  wliieli  I  direct  attention  in  the  special  chapter 
dealing  with  tliis  sul)jeet. 

TiTE  Tntestexes. 

Small  Intestine. — At  birth  the  length  of  the  small  intestine  is  nine  and 
one-half  feet.  The  length  of  the  intestine  may,  however,  vary  with  the  size 
of  the  child.  In  the  duodenum  Brunner's  glands  are  found.  Below  the 
duodenum  Peyer's  patches  are  found.  The  most  important  physiological 
function  of  the  snuill  intestine  consists  in  aiding  the  assimilation  of  food 
by  the  action  of  the  pancreatic  juice  and  other  secretions.  The  emulsifica- 
tion  of  the  fat  in  the  food  takes  place  in  the  small  intestine. 

Length  of  the  Intestine. — The  relative  length  of  the  intestines  in  nurs- 
lings is  greater  than  in  adults,  so  that  the  intestines  are  six  times  as  long  as 
the  body.  Forster  believes  this  is  one  reason  why  nurslings  receive  more 
nourishment  from  milk  than  do  adults.  The  small  intestine  develops  during 
the  first  two  months  of  life  more  than  the  large  intestine,  and  after  the 
second  month  the  reverse  is  true.  The  duodenum  remains  relatively  the 
longer  until  the  end  of  the  fourth  month.  The  transverse  colon  is  the  widest 
and  most  euistic  portion  of  the  large  intestine.  The  continuation  of  the 
large  intestine  in  infants,  into  the  rectum,  is  indicated  by  a  narrowing  at 
this  point. 

Large  Intestine. — According  to  Treves  the  large  intestine  measures: — 

At  birth    1  foot  10  inches,  or  .55      ccntimctors 

At  12  months   2  feet     G  inches,  or  7G      centimeters 

At     6  years  3  feet,                      or  91.5  centimeters 

At  13  years   3  feet     G  inches,  or  107      centimeters 

Course  of  the  Colon. — Erom  the  right  iliac  fossa  up  to  the  liver,  then 
transversely  across  the  abdomen  to  the  spleen  and  then  downward,  ter- 
minating in  the  rectum.  Tlie  colon  forms  at  its  first  turn  the  hepatic 
flexure,  at  the  spleen  the  splenic  flexure,  and  finally  the  sigmoid  flexure. 
The  curve  of  the  sigmoid  flexure  occurs  in  the  left  iliac  fossa. 
(200) 


THE  INTESTINES.  261 

Sigmoid  Flexure. — The  anatomical  illustrations  of  the  sigmoid  flexure 
(see  chapter  on  "Chronic  Constipation")  are  important  to  remember  in 
view  of  the  mechanical  cause  of  constipation  so  frequently  seen  in  young 
children. 

The  transverse  colon,  when  distended  with  gas,  is  very  easily  mapped 
out  by  percussion. 

The  Csecum. — Dwight  found  the  caecum  completely  covered  with  peri- 
toneum in  33  out  of  37  cases  in  young  children.  Treves  states  that  in  100 
cases  observed  by  him,  he  found  the  peritoneum  infolding  the  caecum  in 
all  of  these  cases  on  its  posterior  surface. 

The  caecum  occupies  a  higher  position  anatomically  in  a  child  than 
in  adult  life. 

Vermiform  Appendix. — Behind  the  caecum  lies  the  vermiform  appendix. 
It  is  important  to  remember  that  it  lies  in  the  line  midway  between  the 
umbilicus  and  the  crest  of  the  ilium.  When  the  appendix  is  inflamed  and 
swollen  it  can  frequently  be  mapped  out  by  recto-abdominal  (bimanual) 
palpation. 

Formation  of  Gas  in  the  Intestine. — When  we  consider  the  lesser 
development  of  the  muscles  of  the  intestine,  we  can  readily  understand 
that  peristaltic  movements  are  more  irregular  and  less  forcible,  and  that 
the  muscles  possess  less  tone;  on  this  account  there  is  a  larger  amount  of 
gas  contained  in  the  intestine,  which  constantly  distends  it.  Thus  it  is 
apparent  why  the  abdomen  always  appears  larger  in  the  infant  in  propor- 
tion to  the  other  parts  of  the  body. 

Action  of  Intestinal  Muscles. — The  action  of  the  intestinal  muscles  is 
chiefly  to  transport  the  food  by  a  series  of  peristaltic  movements.  Parts 
of  the  intestine  are  active,  while  others  remain  passive.  Heubner  maintains 
that  post-mortem  examinations  never  show  all  parts  of  the  intestine  in  the 
same  condition,  owing  to  the  irregularity  of  the  muscular  movement. 

Development  of  Glandular  System. — The  development  of  the  glandular 
system  in  infants  is  very  poor,  whereas  the  lymphoid  tissues,  and  follicles,  are 
comparatively  well  developed. 

Lieberkiihn's  glands  are  fewer  in  number  than  in  adults,  whereas  the 
Bruiiner  glands  in  the  duodenum  are  numerous  and  well  developed. 

The  Secretory  and  Absorbing  Power  of  the  Epithelium  and  the  Glands. 
— Heubner  maintains  that  the  secretion  takes  place  from  cells,  located  in 
the  small  intestine,  which  are  scattered  about  and  are  few  in  number, 
whereas  in  the  large  intestine  they  are  far  more  numerous. 

Absorption  of  Fat. — The  absorption  of  fat  takes  place  through  the 
intestinal  epithelium  in  the  duodenum  and  jejunum;  the  glands  also  par- 
ticipate in  this  action.  According  to  the  histological  investigations  by 
Baginsky,  the  real  absorbing  system  of  the  intestinal  wall  is  found  in  the 
connective-tissue  bodies  of  the  mucous  membrane  of  the  infantile  intestine. 


2G2  DISEASES  OF  THE  INTESTINES. 

in  which  are  located  lymphatic  vessels  connected  with  the  larger  lymph- 
chnnnels  of  the  intestine.  The  physiological  and  chemical  functions  are 
much  less  developed  in  infants  than  in  adults  because  the  intestinal  glands 
are  relatively  less  developed. 

Infant  Stools. 

Meconium.  —  The  first  discharge  from  an  infant's  bowels  is  called 
meconium.  It  has  a  greenish -brown  color,  at  times  it  resembles  ink  in 
color.  It  is  composed  of  epithelial  cells,  bile,  cholesterin  crystals,  and  partly 
digested  amniotic  fluid.  Meconium  has  no  odor.  It  is  usually  acid  in 
reaction.  The  color  of  the  infant's  stool  changes  after  a  few  days  of  ma- 
ternal or  bottle-feeding. 

Stool  of  a  Nursling. — The  stool  of  a  nursling  or  a  baby  on  an  exclusive 
-milk  diet  should  be  yellowish  in  color,  smeary  or  pasty-like  in  consistency, 
and  have  an  acid  reaction.  The  smell  should  be  faintly  acid,  but  not  dis- 
agreeable. The  color  is  due  to  bilirubin,  and  the  reaction  depends  on  the 
presence  of  lactic  acid,  the  source  of  which  is  the  milk  sugar.  The  only 
gases  present  are  H  and  CO2.  According  to  Escherich,  H2S  and  CH^,  to 
which  the  odor  of  adult  stools  is  due,  are  not  present.  There  are  no  peculiar 
albuminoids.  Those  existing  in  mothers'  milk  seem  to  be  entirely  absorbed. 
Peptone  exists  in  trifling  amount.  Sugar  is  not  present.  Pancreatic  fer- 
ment is  absent,  and  sometimes  traces  of  pepsin  have  been  found.  Mucus 
is  always  present  in  considerable  quantity;  also  columnar  intestinal  epithe- 
lium. 

In  the  stool  of  nurslings  large  quantities  of  lactnte  of  lime  can  be  found; 
so  also  we  frequently  find  oxalate  of  lime,  depending  on  the  quantity  of 
oxalate  of  lime  ingested.  Uffclmann  has  noted  the  presence  of  bilirubin 
crystals  in  the  stools  of  nurslings,  in  perfectly  healthy  children. 

The  number  of  stools  during  the  first  two  weeks  is  from  three  to  six 
daily.  After  the  first  month  the  average  is  two  stools  daily;  many  infants 
have  one,  others  three  stools  daily.  This  latter  is  due  largely  to  the  excessive 
quantities  of  water  ^iven  to  infants. 

As  soon  as  the  exclusive  milk  diet  is  changed  to  the  mixed  diet  we  then 
lose  the  characteristic  infantile  stool,  and  it  resembles  more  that  of  an  adult, 
though  remaining  softer  and  thinner  throughout  infancy.  The  stools  be- 
come darker  in  color,  assume  the  adult  odor,  and  have  more  varieties  of 
bacteria  than  those  previously  mentioned  as  found  in  the  stool  of  a  milk 
diet. 

Reaction  of  Stools. — Ecaction  of  stools  in  diarrhoeal  disease  and  in 
health  is  chiefly  acid  or,  next  in  frequency,  neutral.  Alkaline  stools  are  rare. 
Grass-green  stools,  usually  acid,  are  seen  in  the  early  stage  of  dyspeptic 
diarrhcca,  the  color  varies  from  a  pale  greenish-yellow  to  grass-green,  owing 
to  improper  food. 


STOOLS.  263 

Wegscheider  has  shown  that  the  green  color  is  the  result  of  preformed 
biliverdin.  The  condition  in  the  intestine,  upon  which  the  transformation 
of  bilirubin  into  biliverdin  depends,  has  been  generally  regarded  as  one  of 
acid  fermentation. 

Expeiiments. — Pfeiffer's  experiments^  show  this  former  opinion  to  be 
wrong.  He  found  that  none  of  the  acids  formed  in  such  fermentation — 
lactic,  acetic,  butyric,  propionic,  etc., — added  to  yellow  stools  outside  the 
body,  turned  them  green,  but  that  they  made  them  deeper  yellow.  But 
dilute  alkaline  solutions  added  to  fresh  yellow  stools  turned  them  green 
after  an  exposure  of  thirty  to  sixty  minutes,  and  strong  solutions  turned 
them,  first,  brown ;  later,  after  exposure  to  air,  intense  green. 

Typical  Green  Stools. — Typical  green  stools  can  be  produced  by  giving 
an  infant  2  or  3  grains  of  bicarbonate  of  soda.  This  I  have  tried  dozens  of 
times;  the  soda  must  be  given  for  a  few  days.  This  explains  Pfeiffer's  alka- 
line theory.  Typical  green  stools  can  also  be  produced  by  giving  small  or 
even  large  doses  of  calomel.  If,  after  having  given  bicarbonate  of  soda  and 
produced  green  stools,  we  give  diluted  hydrochloric  acid  in  5  to  10-drop 
doses,  the  yellow  color  will  reappear  in  a  few  days.  Ehubarb  will  also 
produce  a  yellow  stool. 

Stools  which  are  pale  yellow  when  discharged,  and  which  afterward 
become  green,  are  often  seen  in  disease.  They  may  be  themselves  neutral 
or  alkaline  in  reaction;  this  latter  may,  however,  depend  on  the  admixture 
of  urine.    An  excess  of  bile  may  often  cause  very  green  stools. 

Blood  in  Stools. — Blood  from  the  stomach  or  small  intestine  fre- 
quently gives  the  stool  a  black  color  resembling  tar.  Thus,  a  practical  point 
in  Boas's  "Diagnostik  der  Magen-  und  Darmkrankheiten'^  is  that,  the 
brighter  the  color  of  the  blood,  the  lower  down  near  the  rectum  and  anus 
must  the  pathological  lesion  be  looked  for ;  the  darker  the  blood,  the  higher 
up  must  the  cause  be  found ;  e.g.,  the  diseased  conditions  exist  in  the  stom- 
ach, duodenum,  jejunum,  etc.,  if  the  stool  contain  black  blood.  If  the  cor- 
puscular elements  of  the  blood  are  wanting,  then  the  presence  of  blood  can 
only  be  positively  diagnosticated  by  either  a  microchemical  examination  or 
by  means  of  the  spectroscope.  The  presence  of  red  blood-corpuscles  must 
always  be  regarded  as  a  pathological  factor. 

Brown  Stools;  Muddy  Stools. — A  brown  stool  in  an  infant  is  fre- 
quently caused  by  a  diet  of  animal  food  or  by  a  diet  principally  of  broth. 
These  stools  have  no  distinct  consistency  nor  reaction.  In  dyspeptic  diar- 
rhoea or  in  some  forms  of  enterocolitis  we  have  very  offensive  stools,  and 
they  resemble  muddy  water;  with  the  latter  there  is  considerable  flatus 
during  each  movement.  Brown  stools  may  be  due  to  changed  biliary  pig- 
ment and  to  drugs:    e.g.,  bismuth  causes  the  well-known  dark  stool.     So 

•  "^''erdauung  im  Siluglings-alter  bei  Krankhaften  Zustanden,"  Jahrbuch  fUr 
Eonderheilkimde,  B.  28,  page  164. 


264  DISEASES  OF  THE  INTESTINES. 

al^^o  tannic  acid  and  all  iron  salts  give  the  dai'k  stodl,  wliicli  varies  from  a 
deep  Ijrown  to  a  black  color. 

White  or  lA(jht-(ji(nj  Sluols. — White  or  light-gray  stools  usually  are 
of  a  })utty-like  consistency,  sometimes  like  dry  balls  on  a  diaper;  some- 
time? they  a])pear  like  ashes.  T'sually  they  are  very  offensive,  consisting 
l)rinci})ally  of  fat.  'J'here  is  scarcely  a  trace  of  bile,  or  the  latter  may  be 
absent  altogether. 

Minns. — ]\fucus  is  always  present  in  all  healthy  stools,  and  is  so  well 
mixed  with  the  stool  that  it  does  not  appear  as  mucus  to  the  naked  eye. 
Any  appearance,  therefore,  of  mucus  easily  visible  should  l)e  regarded  as 
abnormal.  ]\lucus  is  present  in  every  form  of  intestinal  disease:  very  abun- 
dant in  inllammatory  conditions  affecting  the  lai'ge  intestine,  more  so  than 
in  those  affections  of  the  small  intestine,  and  especially  so  in  inllammatory 
conditions  of  the  colon,  both  acute  and  chronic. 

Jelhj-liliC  Masses. — Jelly-like  nuisses  or  shreds  of  mucus,  and  cases 
where  the  stool  consists  chiefly  of  mucus,  show  that  the  affection  is  confined 
to  the  lower  portion  of  the  colon  or  that  it  is  located  in  the  rectum. 

Long  Shreds  of  Mucus. — Long  shreds  of  mucus,  frequently  resembling 
false  mend)rane,  are  often  found  in  catarrh  of  the  large  intestine.  If  the 
shreds  of  mucus  are  intimately  mixed  with  the  stool,  then  we  must  look 
for  the  lesion  quite  high  up,  and  if  it  comes  from  the'  snuill  intestine  it  is 
usually  stained  from  bile.  If  the  lesion  is  low  down  the  mucus  is  not 
intimately  mingled  with  the  stool. 

Dyspeptic  Stool. — The  first -change  noticed  in  the  dyspeptic  stool  is 
the  increase  of  fat.  Often  the  stool  is  quite  green  and  contains  small  pieces, 
of  yellowish-white  color,  which  vary  in  size  from  that  of  a  pin-head  to  the 
size  of  an  ordinary  pea.  Hitherto,  from  their  color,  they  were  supposed  to 
be  casein  lumps.  Wegscheider  has  taught  us  that  they  consist  principally 
of  fat.  Baginsky  has  shown  that  large  colonies  of  bacteria  are  contained 
in  these  lumps  of  fat.  Frequently  they  are  so  numerous  that  it  looks  as 
though  the  stool  were  composed  only  of  these  cheesy  lum])S.  They  can  bo 
easily  differentiated  from  real  casein  lumps  by  their  solubility  in  alcohol 
and  ether. 

Ffii  DinrrJian. — Bicdert  and  Demme  have  devoted  considerable  atten- 
tion to  this  subject.^  In  some  children  the  faeces  showed  oO  to  GO  per  cent, 
of  fat,  whereas  the  normal  percentage  in  ordinary  faeces  varied  from  14  to  25 
per  cent,  (which  is  the  normal  quantity),  according  to  Uffelmann. 

Casein  is  not  nearly  as  common  an  ingredient  of  faeces  as  is  commonly 
supposed.  Casein  lumps  can  be  seen  in  al)undance  in  the  course  of  a  diar- 
rhoea during  an  exclusive  diet  of  milk. 

Quantity  of  Fceces. — The  quantity  of  faeces  varies,  but  it  has  been 
found  that  100  grams  of  milk  food  will  produce  about  3  grams  of  faeces, 

1  See  Biedert:     "Fett-Diarrhea,"  in  Jalirbuch  fiir  Kinderheilkunde,  1878. 


STOOLS.  265 

according  to  Baginsky.  This  is  a  vital  point,  but  I  have  found  it  very 
difficult  to  determine,  for  in  most  cases  the  napkins  of  the  infants  are  soiled 
with  urine  plus  the  fseces,  thus  adding  to  the  gross  weight. 

Proteids. — The  proteids  of  milk  are  so  thoroughly  absorbed  that  only 
small  traces  of  them  can  be  found  in  the  fsces. 

Albuminous  decomposition  and  its  products — tyrosin,  indol,  phenol, 
and  skatol — are  not  found  in  milk  fffices.  But  lactic  acid,  acetic  acid,  formic 
acid,  and  other  fatty  acids  are  present,  causing  the  acid  reaction. 

Saccharine  Ferment. — Yon  Jaksch  found  a  saccharine  ferment  in  the 
faeces  of  children. 

Peptonizing  Ferment. — Baginsky  found  a  peptonizing  ferment  also  in 
infantile  faeces. 

Escherich^  says :  "If  albuminous  decomposition  with  very  foul  offen- 
sive stools  exists,  albumins  should  be  withheld  from  the  diet  and  carbo- 
hydrates given,  such  as  dextrin  foods,  sugars,  and  milk.  If  acid  fermentation 
is  present,  with  sour,  l)ut  not  offensive  stools,  carbohydrates  are  to  be  with- 
held and  albuminous  foods  given,  such  as  animal  broths,  Ijouillon,  peptones, 
etc.  In  the  decomposition  of  milk,  the  sugar  of  milk,  and  not  the  casein, 
is  usually  broken  up." 

Holt-  says :  "Eegarding  the  exact  indications  accordiug  to  which  fat, 
sugar,  and  proteids  of  milk  are  to  be  varied,  much  remains  to  be  learned." 

Sugar  is  Too  Low. — If  the  sugar  is  too  low,  the  gain  in  weight  is  apt 
to  be  slower  than  when  furnished  in  proper  amount. 

Sugar  in  E.vcess. — Symptoms  indicating  an  excess  of  sugar :  Colic  or 
thin,  green,  very  acid  stools,  sometimes  causing  irritstion  of  the  buttocks; 
sometimes  there  is  regurgitation  of  food  and  eructations  of  gas. 

Excess  of  Fat. — Excess  of  fat  is  indicated  by  the  frequent  regurgitation 
of  food  in  small  quantities,  usually  one  or  two  hours  after  feeding.  Some- 
times an  excess  of  fat  causes  very  frequent  passages  very  nearly  normal  in 
appearance.  In  some  cases  the  stools  contain  small  round  lumps  somewhat 
resembling  casein,  but  really  masses  of  fat. 

White  Curds  in  the  Stool  of  a  Nursling. — The  small  white  particles 
resembling  cheese  found  in  the  stool  of  a  nursing  infant,  are  frequently 
fat;  more  often  they  are  casein.  A  simple  test  to  determine  the  nature 
of  these  white  particles  is  the  following:  Remove  one  of  these  particles 
with  the  aid  of  a  small  probe  or  piece  of  clean  wood  (a  tooth-pick  will  serve 
quite  well),  and  place  that  white  particle  in  ether,  if  it  dissolves  it  is 
fat;   if  it  does  not  dissolve,  it  is  casein. 

Dry,  Pasty  Stools. — When  too  little  fat  is  given,  it  is  indicated  by  hard, 
dry,  pasty  stools,  and  usually  constipation.    This  can  he  easily  remedied  by 


'  Jahihiicli    fiir    KindiTlicilkmiilc,    "ItcitriijTc    zur    Antis('})tist.'ln'ii    Bt'liamlluiiys- 
methode  (lev   Ma','C'ii-l)aiiiiUriinUlicilcii   des  Siiiiglingsaltors." 
*"AitiHeial  Feeding,''  page  17'J. 


268  DISEASES  OF  niE  INTESTINES. 

the  addition  of  cream,  three-fifths  of  which  is  fat.  Holt  speaks  again=t  in- 
creasing the  fat  above  4.5  per  cent,  in  infants  under  six  months  old,  and 
believes  we  should  not  go  above  4  per  cent. 

Bacteria  of  the  Intestines. 

There  are  a  great  many  bacteria  found  in  the  intestines.  These  are 
present  in  a  normal  infant,  as  well  as  in  an  infant  suffering  from  a  gastro- 
intestinal disorder.  A  great  many  of  these  bacteria  are,  therefore,  non- 
pathogenic. Miller,  who  carefully  studied  the  various  micro-organisms  in 
the  mouth,  found  that  most  of  them  could  again  be  found  in  the  intestinal 
canal.  He  also  found  that  certain  germs  possessed  diastasic  properties,  and 
were  capable  of  producing  lactic-acid  fermentation  in  the  milk-fasces  of 
nurslings. 

Escherich  found  two  germs,  the  one  he  called  '^bacterium  lactis  aerogenes 
(or  bacterium  aceticum,  Baginsky)''  and  the  other  the  bacterium  coll  com- 
mune. In  the  meconium  he  found  proteus  vulgaris,  streptococcus  coli 
gracilis,  and  bacillus  subtilis. 

Bacterium  Coli  Commune  (Escherich).  —  Obtained  by  Emmerich 
(1885)  from  the  blood,  various  organs,  and  the  alvine  discharges  of  cholera 
patients  at  Naples;  by  Weisser  (1886)  from  normal  and  abnormal  human 
fffices,  from  the  air,  and  from  putrefying  infusions;  by  Escherich  (1886) 
from  the  fasces  of  healthy  children;  since  shown  to  be  constantly  present 
in  the  alvine  discharges  of  healthy  men,  and  probably  of  many  of  the  lower 
animals.  Found  by  Sternberg  in  the  blood  and  various  organs  of  yellow- 
fever  cadavers  in  Havana  (1888  and  1889). 

Numerous  varieties  have  been  cultivated  by  different  bacteriologists, 
which  vary  in  pathogenic  power  and  to  some  extent  in  their  growth  in 
various  culture  media;  but  the  differences  described  are  not  sufficiently 
characteristic  or  constant  to  justify  us  in  considering  them  as  distinct 
species. 

Morphology. — Differs  considerably  in  its  morphology  as  obtained  from 
different  sources  and  in  various  culture  media.  The  typical  form  is  that 
of  short  rods  with  rounded  ends,  from  2  to  3  microns  in  length  and  0.4  to 
0.6  micron  broad;  but  under  certain  circumstances  the  length  does  not 
exceed  the  breadth — about  0.5  micron — and  it  might  be  mistaken  for  a 
micrococcus;  again  the  prevailing  form  in  a  culture  is  a  short  oval;  fila- 
ments of  5  microns  or  more  in  length  are  often  observed  in  cultures,  asso- 
ciated with  short  rods  or  oval  cells.  The  bacilli  are  frequently  united  in 
pairs.  The  presence  of  spores  has  not  been  demonstrated.  In  unfavorable 
culture  media  the  bacilli,  in  stained  preparations,  may  present  unstained 
places,  which  are  supposed  by  Escherich  to  be  due  to  degenerative  changes 
in  the  protoplasm.  Under  certain  circumstances  some  of  the  rods  in  a  pure 
culture  have  been  observed  by  Escherich  to  present  spherical,  unstained  por- 


BACTERIA  OF  THE  INTESTINES. 


267 


tions  at  one  or  both  extremities,  which  closely  resemble  spores,  but  which 
he  was  not  able  to  stain  by  the  methods  usually  employed  for  staining 
spores,  and  which  h"e  is  inclined  to  regard  as  "involution  forms." 

The  bacillus  stains  readily  with  the  aniline  colors  usually  employed 
by  bacteriologists,  but  quickly  parts  with  its  color  when  treated  with  iodine 
solution — Gram's  method — or  with  diluted  alcohol. 

Biological  CJiaracters. — "An  aerobic  and  facultative  anaerobic,  non- 
liquefying  bacillus.  Sometimes  exhibits  independent  movements,  which 
are  not  very  active.  One  rod  of  a  pair,  in  a  hanging-drop  culture,  may 
advance  slowly  with  a  to-and-fro  movement,  while  the  other  follows  as  if 
attached  to  it  by  an  invisible  band  (Escherich).  The  writer's  personal 
observations  lead  him  to  believe  that,  as  a  rule,  this  bacillus  does  not  exhibit 


Fig.  O'.t. — llactorium   C  oli   Coinmime. 


independent  movements.  Does  not  form  spores.  Grows  m  various  culture 
tuedia  at  the  room  temperature — more  rapidly  in  tlie  incubating  oven. 
Grows  in  a  decidedly  acid  medium. 

In  gelatine  plates,  colonies  are  developed  in  from  twenty-four  to 
forty-eiglit  liours,  wliich  vary  considerably  in  their  a])pearance  according  to 
their  age,  and  in  different  cultures  in  the  same  medium.  The  deep  colonies 
are  usually  spherical  and  at  first  are  transparent,  homogeneous,  and  of  a 
pale  straw  or  amber  color  by  transmitted  light ;  later  they  frequently  have  a 
dark-brown,  opaque  central  portion  surrounded  by  a  more  transparent  pe- 
ripheral zone ;  or  they  may  be  coarsely  granular  and  opaque ;  sometimes  they 
have  a  long  oval  or  "whetstone"  form.  The  superficial  colonies  differ  still 
more  in  appearance ;  very  young  colonies  by  transmitted  light  often  resemble 


268  DISEASES  OF  THE  INTESTINES. 

little  drops  of  water  or  fragments  of  broken  glass;  when  they  have  suffi- 
cient space  for  their  develoj^ment  they  quickly  increase  in  size  and  may 
attain  a  diameter  of  three  to  four  centimeters;  the  centi-al  portion  is  thick- 
est, and  is  often  marked  by  a  spherical  nucleus  of  a  dark-brown  color  when 
the  colony  has  started  below  the  surface  of  the  gelatine;  the  margins  are 
thin  and  transparent,  the  thickness  gradually  increasing  toward  the  center, 
as  does  also  the  color,  which  by  transmitted  light  varies  from  light-straw 
color  or  amber  to  a  dark  brown.  The  outlines  of  superficial  colonies  are 
more  or  less  irregular,  and  the  sui-face  may  be  marked  by  ridges,  fissures, 
or  concentric  rings,  or  it  may  be  granular.  The  writer  has  observed  colonies 
resembling  a  rosette,  or  a  daisy  with  expanded  petals.  Escherich  speaks  of 
colonies  which  present  star-shaped  figures  surrounded  by  concentric  rings. 

"In  gelatine  stick  cultures  the  growth  upon  the  surface  is  rather  dry, 
and  may  be  quite  thin,  extending  over  the  entire  surface  of  the  gelatine,  or 
it  may  be  thicker,  with  irregular,  leaf-like  outlines  and  with  superficial  in- 
crustations or  concentric  annular  markings.  An  abundant  development 
occurs  all  along  the  line  of  puncture,  which,  in  the  deeper  portion  of  the 
gelatine,  is  made  up  of  more  or  less  closely  crowded  colonies ;  these  are  white 
by  reflected  light,  and  of  amber  or  light-brown  color  by  transmitted  light; 
later  they  may  become  granular  and  opaque.  Frequently  a  diffused  cloudy 
appearance  is  observed  near  the  surface  of  the  gelatine,  and  under  certain 
circumstances  branching,  moss-like  tufts  develop  at  intervals  along  the 
line  of  growth.  One  or  more  gns  l^ublilcs  mnj  often  be  seen  in  recent  stick 
cultures  in  gelatine. 

"Upon  nutrient  agar  and  blood-serum,  in  the  incubating  oven,  an  abun- 
dant, soft,  shining  layer  of  a  brownish-yellow  color  is  developed.  The 
growth  upon  potato  differs  considerably,  according  to  the  age  of  the  potato. 
According  to  Escherich,  upon  old  potatoes  there  may  be  no  growth,  or  it 
may  be  scanty  and  of  a  white  color.  In  milk  at  ;r/°  C,  an  acid  reaction 
and  coagulation  of  the  casein  are  produced  at  the  end  of  eight  or  ten  days. 
Tn  the  absence  of  oxygen  this  bacillus  is  al)le  to  gi'ow  in  solutions  contain- 
ing grape  sugar  (Escherich).  Tn  bouillon  it  grows  ra])i(lly,  producing  a 
milky  opacity  of  the  culture  liquid.  The  thermal  death  point  of  Em- 
merich's bacillus,  and  of  tlie  colon  bacillus  from  fa>ces,  was  found  l)y  Weis- 
ser  to  be  60°  C,  the  time  of  exposure  being  ten  minutes.  The  author  has 
obtained  corresponding  results.  Weisser  found  that  when  the  bacilli  from 
a  bouillon  culture  were  dried  upon  thin  glass  covers  they  failed  to  grow 
after  twenty-four  hours.  These  results  give  confirmation  to  the  view  that 
the  bacillus  under  consideration  does  not  form  spores. 

"Pathogenesis. — Comparatively  small  amounts  of  a  ])ure  culture  of  the 
colon  bacillus  injected  into  the  circulation  of  a  guinea  pig  usually  cause  the 
death  of  the  animal  in  from  one  to  three  days,  and  the  bacillus  is  found  in 
considerable  numbers  in  its  blood.     But,  when  injected  subcutaneously  or 


BACTERIA  OF  THE  INTESTINES.  269 

into  tliG  peritoneal  cavit}^  of  rabbits  or  guinea  pigs,  a  fatal  termination 
depends  largely  on  the  quantity  injected;  and,  although  the  bacillus  may 
be  obtained  in  cultures  from  the  blood  and  the  parenchyma  of  the  various 
oi-gans,  it  is  not  present  in  large  numbers,  and  death  appears  to  be  due  to 
toxaemia  rather  than  to  septica?mia.  Mice  are  not  susceptible  to  infection 
by  subcutaneous  injection.  Small  quantities  injected  underneath  the  skin 
of  guinea  pigs  usually  produce  a  local  abscess  only;  larger  amounts — 2  to 
5  cubic  centimeters — frequently  produce  a  fatal  result,  with  symptoms  and 
pathological  appearances  corresponding  with  those  resulting  from  intra- 
\enous  injection.  These  are  fever,  developed  soon  after  the  injection,  diar- 
vlicea,  and  symptoms  of  collapse  appearing  shortly  before  death.  At  the 
;mtopsy  the  liver  and  sjileen  appear  normal,  or  nearly  so;  the  kidneys  are 
congested  and  may  present  scattered  punctiform  ecchymoses  (Weisser). 
According  to  Escherich,  the  spleen  is  often  somewhat  enlarged.  The  small 
intestine  is  hypcra^mic,  especially  in  its  upper  portion,  and  the  peritoneal 
layer  presents  a  rosy  color;  the  mucous  membrane  gives  evidence  of  more 
or  less  intense  catarrhal  inflammation,  and  contains  mucus,  often  slightly 
mixed  with  blood.  In  ral)bits  death  occurs  at  a  somewhat  later  date,  and 
diarrhoea  is  a  common  symptom.  In  dogs  the  subcutaneous  injection  of  a 
considerable  quantity  of  a  pure  culture  may  give  rise  to  an  extensive  local 
abscess/' 

Varieties. — Booker,  in  his  extended  studies  relating  to  the  bacteria 
present  in  the  fa?ces  of  infants  suffering  from  summer  diarrhoea,  has  isolated 
seven  varieties  "which  closely  resemble  bacterium  coli  commune  in  mor- 
phology and  growth  in  agar,  neutral  gelatine,  and  potato,  but  by  means  of 
otiier  tests  a  distinction  can  be  made  between  them."  These  are  described 
a^^  follows : — 

"Bacillus  'L'  of  Booker. — Found  in  two  cases  of  cholera  infantum  and 
the  predominating  form  in  one  serious  case  of  catarrhal  enteritis. 

"Morphology. — Resembles  bacterium  coli  commune. 

"Groivtli  in  Colonies. — Gelatine:  Colonies  grow  luxuriantly  in  gelatine, 
and  thrive  in  acid  and  sugar  gelatine  equally  as  well  as  in  neutral  gelatine. 
In  the  latter  the  colonies  closely  resemble,  but  are  not  identical  with,  the 
i)ncterium  coli  commune.  In  acid  gelatine  they  differ  very  much  from  bac- 
terium coli  coniniune.  The  colonies  spread  extensively,  and  are  bluish 
white,  with  concentric  rings.  Slightly  magnified,  they  have  a  large,  uni- 
form, yellow  ceciral  zone  surrounded  by  a  border  compt)sed  of  perpendicular 
threads  ])laced  thickly  together.  Sometimes  a  series  of  these  rings  a})pear, 
with  intervening  yel!ow  rings. 

"Agar:  The  colonies  are  round,  spread  out.  and  blue  or  bluish  white. 
Slightly  magnified,  they  have  a  ]):ile-yellow  color. 

"Stab  Cultures. — Gelatine:  In  sugar  gelatine  the  surface  growth  lias 
a  nearly  colorless  center  surrounded  by  a  thick  border,  with  an  outer  edge 


270  DISEASES  OF  THE  INTESTINES. 

of  fine,  hair-like  fringe;  the  growth  along  the  line  of  inoculation  is  fine 
and  delicate.  In  neutral  gelatine  the  growth  is  not  so  luxuriant  as  on  sugar 
gelatine;  on  the  surface  it  is  thick  and  white,  with  a  delicate  stalk  in  the 
depth. 

"Agar :  Thick  white  surface  growth,  with  a  Avcll-developed  stalk  in  the 
depth. 

"Potato:  Luxuriant  yellow,  glistening,  moist,  and  slightly  raised  sur- 
face, with  well-defined  borders. 

"Action  on  Milk. — Coagulated  into  a  gelatinous  coagulum  in  twenty- 
four  hours  at  38°  C,  and  into  a  solid  clot  in  two  days. 

"Milh-Litmus  Reaction. — Milk  colored  blue  with  litmus  is  changed  to 
light  pink  in  twenty-four  hours  at  38°  C.  The  pink  color  gradually  fades, 
and  by  the  second  or  third  day  is  white  or  cream  color,  with  a  thin  layer 
of  pink  on  top.  The  pink  color  extends  in  a  few  days  about  one-half  down 
the  clot. 

"Temperature. — Grows  best  about  38°  C. 

"Spores  have  not  been  observed. 

"Gas-production. — Gas  bubbles  are  produced  in  milk;  not  observed 
on  potato.'' 

"Bacillus  *E'  of  Booker. — Found  as  the  predominating  form  in  two 
cases  of  dysentery,  one  of  which  was  fatal  and  the  other  a  mild  case. 

"Morphology. — Eesembles  bacterium  coli  commune. 

"Growth  in  Colonies. — Gelatine:  The  colony  growth  varies  consider- 
ably with  slight  difference  in  the  gelatine.  In  10  per  cent,  neutral  gela- 
tine the  colonies  resemble  those  of  bacterium  coli  commune.  On  the  second 
or  third  day,  when  the  colonies  have  just  broken  through  the  surface  and 
are  spread  out,  it  is  impossible  to  distinguish  one  variety  from  the  other, 
but  as  the  colonies  grow  older  a  difference  can  generally  be  recognized.  In 
sugar  and  acid  gelatine  the  colonies  have  a  clear  center  with  white  border. 
Slightly  magnified,  a  uniform  brown  center  surrounded  by  a  brown  zone 
composed  of  fine,  needle-like  rays  perpendicular  to  the  border.  After  cul- 
tivating for  a  few  generations  on  acid  and  sugar  gelatine  the  colonies  cease 
to  develop,  and  either  grow  in  very  small  colonies  or  do  not  grow  at  all. 
The  activity  is  regained  if  cultivated  on  neutral  gelatine. 

"Agar:  Colonies  are  large,  round,  and  have  a  mother-of-pearl  appear- 
ance.    Slightly  magnified,  a  uniform  yellow  color. 

"Stab  Cidtures. — Agar:  Luxuriant,  nearly  colorless  surface  growth, 
with  well-developed  stalk  along  the  line  of  inoculation  in  the  depth. 

"Potato:  Golden-yellow,  glistening,  slightly  raised  surface,  with  well- 
defined  borders. 

"Action  on  Milh. — Milk  becomes  gelatinous  in  twenty-four  hours  at 
38*  C,  and  in  a  few  days  a  solid  coagulum  is  formed.  Milk  colored  blue 
with  litmus  is  reduced  to  white  or  cream  color  in  twenty-four  to  forty- 


Bacteria  of  the  intestines.  271 

eight  hours  at  38°  C,  with  a  thin  Uiyer  of  pink  at  the  top  of  the  culture. 
The  pink  color  gradually  extends  lower  in  the  coaguluni. 

"Temperature. — Thrives   best   at  about   38°    C. 

"Spores  have  not  been  observed. 

"Gas-production. — Occurs  in  milk,  but  not  seen  in  potato  cultures. 

"Relation  to  Gelatine. — Does  not  liquefy  gelatine. 

"Resemblance. — Eesembles  bacterium  coli  commune  and  bacillus  'd/ 
differing  from  the  former  in  the  character  of  the  colony  growth  on  acid 
and  sugar  gelatine  and  in  ceasing  to  develop  in  these  media  after  several 
generations.    It  differs  from  bacillus  'd'  in  this  latter  respect." 

"Bacillus  T'  of  Booker.— Found  in  one  case  of  cholera  infantum  and 
one  case  of  catarrhal  enteritis. 

"Morphology. — Eesembles  bacterium  coli  commune. 

"Growth  in  Colonies. — Gelatine :  It  is  difficult  to  distinguish  the  colony 
growth  from  the  bacterium  coli  commune.  There  is  often  a  difEerence  in 
the  colonies  planted  at  the  same  time  and  kept  under  similar  conditions, 
but  it  is  not  very  marked  nor  always  the  same  kind  of  difference.  The 
tendency  to  concentric  rings  is  greater  in  this  variety.  The  colonies  develop 
somewhat  better  on  neutral  and  sugar  gelatine  than  on  acid  gelatine. 

"Agar:  The  colonies  are  large,  round,  and  bluish  white.  Slightly 
magnified,  a  light-yellow  color. 

"Stah  Cultures. — Gelatine:  The  culture  is  spread  over  the  surface 
and  has  a  mist-like  appearance;  in  the  depth  along  the  line  of  inoculation 
is  a  delicate  stalk. 

"Agar:  Thick,  luxuriant,  white  surface  growth,  with  a  well-developed 
stalk  along  the  line  of  inoculation  in  the  depth. 

"Potato:  Bright-yellow,  glistening,  moist  surface,  with  well-defined 
borders,  and  but  slightly  raised  above  the  surrounding  potato. 

"Action  on  Milk  and  Litmus  Reaction. — Milk  is  coagulated  into  a  solid 
clot  in  twenty-four  hours  at  38°  C,  and  in  forty-eight  hours  is  reduced  to 
white  or  cream  color  with  a  thin  pink  layer  on  top. 

"Gas-production. — Gas  bubbles  arise  in  milk  cultures,  but  they  have 
not  been  observed  on  potato  cultures. 

"Temperature. — Grows  better  at  38°  C. 

"Spores  have  not  been  observed. 

"Relation  to  Gelatine. — Does  not  liquefy  gelatine. 

"Resemblance.  —  It  closely  resembles  bacterium  coli  commune  and 
Brieger's  bacillus  in  the  character  of  its  growth  upon  different  media,  but 
is  readily  distinguished  from  both,  as  is  also  Brieger's  bacillus  from  the 
bacterium  coli  commune,  by  the  following  differential  test  recently  made 
known  by  Dr.  Mall :  Yellow  elastic  tissue  from  the  ligamentum  nuchas  of  an 
ox  is  cut  into  fine  bits  and  is  placed  in  test  tubes  containing  water  with 
10  per  cent,  bouillon  and  1  per  cent,  sugar,  and  sterilized  from  one  and 


272  DISEASES  OP  THE  INTESTINES. 

one-half  to  two  hours  at  a  time  for  three  consecutive  days.  Into  this  is 
inociTlated  two  species  of  bacteria,  one  of  which  is  the  bacterium  under 
observation,  the  other  a  bacillus  found  in  garden  earth.  The  latter  bacillus 
is  anaerobic;  grows  in  hydrogen,  nitrogen,  and  ordinary  illuminating  gas; 
in  the  bottom  of  bouillon;  in  the  depth,  but  not  on  the  surface,  of  agar 
stab  cultures,  and  not  at  all  in  gelatine  stab  cultures.  It  has  a  spore  in  one 
end,  making  a  knob  bacillus.  Different  species  of  bacteria — streptococcus 
indicus,  tetragenus,  cholera,  swine  plague,  bacterium  lactis  aerogenes,  bac- 
terium coli  commune,  Brieger's  bacillus,  and  a  number  of  varieties  of  bac- 
teria which  I  have  isolated  from  the  faeces — were  inoculated  with  head 
bacillus  into  the  above  described  elastic  tissue  tubes.  The  tubes  inoculated 
with  Brieger's  bacillus  develop  a  beautiful  purple  tint,  which  started  as  a 
narrow  ring  at  the  top  of  the  culture,  gradually  extending  downward  and 
deepening  in  color  until  the  whole  tube  has  a  dark-purple  color.  This  color 
reaction  began  in  five  to  fourteen  days,  and  was  constantly  present  in  a 
large  number  of  tests.  Tubes  inoculated  with  bacillus  T  gave  a  much 
fainter  purple  color,  which  was  longer  in  appearing  and  never  became  so 
dark  as  with  Brieger's  bacillus. 

"Tubes  inoculated  with  the  other  species  of  bacteria  above  mentioned 
gave  no  color  change  and  remained  similar  to  control.  Bacillus  T  also 
shows  a  slight  difference  from  bacterium  coli  commune  in  coagulating  milk 
and  reducing  litmus  more  rapidly,  and  appears  to  produce  more  active  fer- 
mentation in  milk.  Like  Brieger's  bacillus,  the  gelatine  colonies  more  fre- 
quently show  a  concentric  arrangement  than  those  of  the  bacterium  coli 
commune." 

"Bacillus  *G'  of  Booker. — Found  in  one  case  of  serious  gastro-enteric 
catarrh.    It  was  not  in  large  quantity. 

"Morphology  and  Biological  Characters. — In  morphology,  character 
of  growth  on  agar,  gelatine,  and  potato,  it  resembles  bacterium  coli  com- 
mune. 

"Action  on  Milk  and  Litmus  Reaction. — Milk  is  not  coagulated,  and 
milk  colored  blue  with  litmus  is  changed  to  pink  in  a  few  days,  and  holds 
this  color.  These  characteristics  distinguish  it  from  the  bacterium  coli 
commune. 

"Gas-production. — Not  observed  in  milk  or  potato  cultures. 

"Relation  to  Gelatine. — Does  not  liquefy  gelatine." 

"Bacillus  'H'  of  Booker. — Found  in  one  case  of  mild  dysentery,  not 
in  large  quantity. 

"Morphology. — Eesembles  bacterium  coli  commune. 

"Growth  in  Colonies. — Gelatine:  In  plain  neutral  gelatine  the  colonies 
resemble  those  of  bacterium  coli  commune.  In  sugar  gelatine  the  colonies 
are  white  and  spread  extensively.     Slightly  magnified,  they  have  a  round, 


BACTERIA  OF  THE  INTESTINES.  273 

dark  center  surrounded  by  a  yellow,  loose  zone  with  an  outer  white  rim; 
later  the  whole  colony  has  a  uniform  yellow  color  and  is  not  compact. 

"Agar:  Colonies  are  white,  round,  and  large.  Slightly  magnified, 
they  are  brownish  yellow. 

"Stab  Cultures. — Xothing  characteristic  in  gelatine  and  agar. 

"Potato  culture  is  yellow,  dry,  and  slightly  raised,  with  well-defined 
borders. 

"Action  on  Milk  and  Litmus  Reaction. — Milk  is  coagulated  into  a  solid 
clot  in  two  days  at  38°  C.  Milk  colored  blue  with  litmus  is  changed  to 
pink  in  twenty-four  hours. 

"Gas-production. — Occurs  in  milk;   not  observed  on  potato. 

"Relation  to  Oelatine. — Does  not  liquefy  gelatine." 

"Bacillus  'K'  of  Booker. — Found  in  two  cases  of  cholera  infantum  and 
oae  of  catarrhal  enteritis. 

"Morphology. — Eesembles  bacterium  coli  commune. 

"Growth  in  Colonies — Gelatine:  In  neutral  gelatine  the  colonies  can- 
not be  distinguished  from  those  of  bacterium  coli  commune.  In  acid  gela- 
tine the  colonies  do  not  spread  so  extensively  as  those  of  bacterium  coli 
commune,  and  they  have  a  decided  concentric  arrangement;  a  wide  white 
center  surrounded  by  a  narrow,  transparent  blue  ring;  and  outside  of  this 
a  white  border.  Slightly  magnified,  the  colonies  have  an  irregular,  yellow- 
ish-brown center,  mottled  over  with  dark  spots  and  surrounded  by  a  light- 
yellow  ring  bordered  by  a  brownish-yellow  wreath. 

"Agar:  Colonies  are  large,  round,  and  bluish  white.  Slightly  mag- 
nified, a  light-brownish-yellow  color. 

"Stab  Cultures. — Gelatine:  In  sugar  gelatine  the  surface  growth  is 
extensive;  nearly  colorless;  and  has  a  rough,  misty  appearance.  In  the 
depth  is  a  delicate  growth.  In  plain  neutral  gelatine  the  surface  growth 
is  bluish  white,  thick,  and  not  so  extensively  spread;  the  growth  in  the 
depth  is  also  thicker. 

"Potato  culture  is  moist,  dirty-cream  color,  has  raised  surface  and 
defined  border. 

"Action  on  Milk. — Milk  becomes  gelatinous  in  twenty-four  hours  at 
38"  C,  and  a  solid  clot  in  two  days.  Milk  colored  blue  with  litmus  is 
changed  to  pink  in  twenty-four  hours,  and  reduced  to  white,  with  a  pink 
layer  on  top,  in  two  days." 

"Bacillus  'N'  of  Booker. — Found  in  large  quantity,  but  not  the  pre- 
dominating form,  in  one  case  of  chronic  gastro-enteric  catarrh  (extremely 
emaciated). 

"Morphology. — Eesembles  bacterium  coli  commune. 

"Growth  in  Colonies. — Gelatine :  In  neutral  gelatine  the  colonies  are 
spread  out  and  have  a  frosty,  or  ground-glass,  appearance.  The  center  is 
blue  and  border  white,  but  both  have  the  ground-glass  appearance.    Slightly 


274  DISEASES  OF  THE  INTESTINES. 

magnified,  the  central  part  is  light  yellow  and  the  border  brown,  with  a 
rough,  furrowed  surface.  In  acid  gelatine  the  white  border  is  wider  and 
the  surface  is  rougher. 

"Agar:  Colonies  are  round,  blue,  or  bluish  white,  and  spread  out 
Under  the  microscope  they  have  a  light-yellow  color. 

"Stab  Cultures. — Gelatine:  Has  a  rough,  nearly  colorless  surface 
growth,  and  a  thick  stalk  in  the  depth  along  the  line  of  inoculation. 

"Agar:  Thick  white  surface  growth,  with  well-developed  stalk  in  the 
depth. 

"Action  on  Milk  and  Litmus  Reaction. — Milk  remains  liquid  and 
milk  colored  blue  with  litmus  is  changed  to  pink. 

"Gas-production. — Not  observed  in  milk  or  potato  cultures. 

"Relation  to  Gelatine. — Does  not  liquefy  gelatine. 

"Spores  have  not  been  noticed."^ 

Bacterium  Lactis  Aerogenes.  —  Synonym:  Bacillus  lactis  aerogenes 
(Escherich). 

Obtained  by  Escherich  (1886)  from  the  contents  of  the  small  intestine 
of  children  and  animals  fed  on  milk;  in  smaller  numbers  from  the  faeces 
of  milk-fed  children,  and  in  one  instance  from  uncooked  cows'  milk. 

Morphology. — Short  rods  with  rounded  ends,  from  1  to  2  microns  in 
length  and  from  0.1  to  0.5  micron  broad;  short-oval  and  spherical  forms 
are  also  frequently  observed,  and  under  certain  circumstances  longer  rods 
— 3  microns — may  be  developed;  usually  united  in  pairs,  and  occasionally 
in  chains  containing  several  elements.  In  some  of  the  larger  cells  Escherich 
has  observed  unstained  spaces,  but  was  not  able  to  obtain  any  evidence  that 
these  represent  spores. 

This  bacillus  stains  readily  with  the  ordinary  aniline  colors,  but  does 
not  retain  its  color  when  treated  by  Gram's  method. 

Biological  Characters. — An  aerobic  (facultative  anaerobic),  non- 
liquefying,  non-motile  bacillus.  Does  not  form  spores.  Grows  in  various 
culture  media  at  the  room  temperature — more  rapidly  in  the  incubating  oven. 
Upon  gelatine  plates,  at  the  end  of  twenty-four  hours,  small,  white  colonies 
are  developed.  Upon  the  surface  these  form  hemispherical,  soft,  shining 
masses  which,  examined  under  the  microscope,  are  found  to  be  homogeneous 
and  opaque,  with  a  whitish  luster  by  reflected  light.  The  deep  colonies  are 
spherical .  and  opaque,  and  attain  a  considerable  size.  In  gelatine  stick 
cultures  the  growth  resembles  that  of  Friedlander's  bacillus ;  i.e.,  an  abun- 
dant growth  along  the  line  of  puncture  and  a  rounded  mass  upon  the  sur- 
face, forming  a  "nail-shaped"  growth.  In  old  cultures  the  upper  part  of 
the  gelatine  is  sometimes  clouded,  and  numerous  gas  bubbles  may  form  in 
the  gelatine.  Upon  the  surface  of  nutrient  agar  an  abundant,  soft,  white 
layer  is  developed.    Upon  old  potatoes,  in  the  incubating  oven,  at  the  end 


Sternberg's  "Manual  of  Bacteriology/'  1892. 


BACTERIA  OF  THE  INTESTINES. 


275 


of  twenty-four  hours  a  yellowish-white  layer,  several  millimeters  thick,  is 
developed,  which  is  of  paste-like  consistence  and  contains  about  the  periph- 
ery a  considerable  number  of  small  gas  bubbles ;  this'  layer  increases  in 
dimensions,  has  an  irregular  outline,  and  larger  and  more  numerous  gas 
bubbles  are  developed  about  the  periphery,  some  the  size  of  a  pea;  later  the 
whole  surface  of  the  potato  is  covered  with  a  creamy,  semifluid  mass  filled 
with  gas  bubbles.  On  young  potatoes  the  development  is  different;  a  rather 
luxuriant,  thick,  white  or  pale-yellow  layer  is  formed,  which  is  tolerably 
dry  and  has  irregular  margins;  the  surface  is  smooth  and  shining,  and  a 
few  minute  gas  bubbles  only  are  formed  after  several  days. 


Fis:.  70. — Bacterium  Lactis  Aerosrenes. 


Pathogenesis. — Injections  of  a  considerable  quantity  of  a  pure  culture 
into  the  circulation  of  rabbits  and  of  guinea  pigs  give  rise  to  a  fatal  result 
within  forty-eight  hours. 

In  his  first  publication  relating  to  "the  bacteria  found  in  the  dejecta  of 
infants  afflicted  with  summer  diarrhoea,"  Booker  has  described  a  bacillus 
which  he  designates  by  the  letter  "h,"  which  closely  resembles  bacillus  lactis 
aerogenes  and  is  probably  indentical  with  it.    He  says : — 

"Summary  of  Bacillus  'h.' — Found  nearly  constantly  in  cholera  in- 
fantum and  catarrhal  enteritis,  and  generally  the  predominating  form.  It 
appeared  in  larger  quantities  in  the  more  serious  cases.  It  was  not  found  in 
the  dysenteric  or  healthy  faeces.  It  resembles  the  description  of  the  bacillus 
lactis  aerogenes,  but  the  resemblance  does  not  appear  sufficient  to  constitute 
an  identity,  and,  in  the  absence  of  a  culture  of  the  latter  for  comparison, 
it  is  considered  a  distinct  variety  for  the  following  reasons:    Bacillus  V 


276  DISEASES  OF  THE  INTESTINES. 

is  uniformly  larger,  its  ends  are  not  so  sharply  rounded,  and  in  all  culture 
media,  long  thick  filaments  are  seen,  and  many  of  the  bacilli  have  the  pro- 
toplasm gathered  in  the  center,  leaving  the  poles  clear.  There  is  some  dif- 
ference in  their  colony  growth  on  gelatine,  and  in  gelatine  stick  cultures 
bacillus  %'  does  not  show  the  nail-form  growth  with  marked  end  swelling 
in  the  depth.  In  potato  cultures  the  bacillus  lactis  aerogenes  shows  a  dif- 
ference between  old  and  new  potatoes,  while  bacillus  'b'  does  not  show  any 
difference. 

"Bacillus  'h'  possesses  decided  pathogenic  properties,  which  were  shown 
both  by  hypodermic  injections  and  feeding  with  milk  cultures.*' 

Diarrhoea.* 

By  diarrhoea  is  meant  too  frequent  stools.  This  increased  peristalsis 
is  usually  due  to  some  specific  cause.  Infants  on  a  liquid  diet  are  more 
prone  to  loose  evacuations  than  older  children  on  a  solid  or  semi-solid  diet. 
Children  suffering  from  rickets  or  athrepsia  infantum,  or  any  form  of  mal- 
nutrition, are  more  prone  to  the  development  of  diarrhoea.  The  cause  of 
the  bulk  of  the  cases  of  diarrhoea  seen  by  me  during  the  last  fifteen  years 
in  one  of  the  largest  dispensaries  of  New  York  City,  was  bottle-feeding.  Out 
of  1000  cases  of  diarrhoea  900  were  bottle-fed  and  lived  amid  poor  hygienic 
surroundings.  In  90  cases  the  children  were  breast-fed,  but  there  was  a 
disturbance  during  lactation.  This  disturbance  was  pregnancy,  menstrua- 
tion, tuberculosis,  or  syphilis  in  the  mother,  or  prolonged  nursing  with 
deficient  fats  and  proteids. 

In  10  cases  there  was  no  assignable  cause  excepting  the  subnormal  con- 
dition of  the  body  due  to  an  excess  of  midsummer  heat. 

Contaminated  Milh. — Impurities  such  as  bacteria,  filth,  and  chemical 
products  due  to  fermentation  can  easily  cause  diarrhoea.  In  my  article  on 
"Bacteria  in  the  Intestine,*'  I  describe  the  two  most  frequent  varieties  of 
bacteria  which  are  normally  found  in  the  intestine.  They  are  the  bac- 
terium coli  and  the  bacterium  lactis.  These  bacteria  frequently  assume  a 
virulent  form  under  certain  conditions.  They  very  often  cause  diarrhoea. 
Other  bacteria,  such  as  the  streptococci,  can  be  introduced  in  cows'  milk. 
A  diseased  udder  in  the  cow  will  frequently  secrete  pus  in  addition  to  milh. 
Such  milk  must  necessarily  cause  trouble  when  introduced  into  the  in- 
fantile stomach  or  bowels. 

Improper  Diet  for  Older  Children. — We  frequently  see  people  who 
think  it  wise  to  give  their  children,  regardless  of  their  age,  a  bit  of  any- 
thing from  the  table.  Eaw  fruits  and  raw  vegetables,  cabbage,  and  pickles 
are  given  regardless  of  the  consequences.    In  studying  the  dietetic  sins  com- 


*  See  also  chapter  on  "Acute  Milk  Infection.** 


DIARRH(EA.  277 

mitted  by  the  parents  of  children  in  two  dispensaries  located  in  different 
sections  of  New  York  City,  I  found  the  following  conditions : — 

One  hundred  children  between  the  second  and  sixth  years  of  age 
living  in  tenements  apparently  healthy;  80  received  a  taste  of  beer  or  a 
drop  of  whisky  diluted  with  water  every  day.  In  some  families  the  children 
received  as  much  as  a  wineglassful  and  more  of  beer  with  each  meal.  Such 
imprudence  is  frequently  a  distinct  factor  in  the  causation  of  diarrhoea. 

Nervous  Diarrhoea. — The  influence  of  fright  or  excitement  is  the  best 
example  of  diarrhoea  due  to  nervous  influence  that  can  be  given.  When 
caused  by  a  nervous  influence  the  faeces  contain  mucus,  and  there  is  usually 
an  explosive  stool.  It  is  a  form  of  e:saggerated  peristalsis.  Chilling  the 
surface  of  the  body  frequently  provokes  diarrhoea. 

Diarrhoea  as  a  Sjnnptom  of  Disease. — Xature's  method  of  eliminating 
poison  is  frequently  seen  when  a  diarrhoea  commences  in  the  course  of  an 
acute  infectious  disease.  Toxic  products  can  best  be  eliminated  by  the 
emunctories,  and  the  intestines  are  one  of  the  most  valuable  agents  for 
eliminating  poison  from  the  body.  The  diarrhoea  of  typhoid  fever,  sum- 
mer complaint,  dysentery,  and  ileo-colitis  have  been  described  in  their 
respective  chapters. 

Treatment. — Seek  the  cause  and  if  possible  remove  the  same.  If  a 
dietetic  error  has  caused  the  diarrhoea,  then  a  good  dose  of  castor-oil  should 
be  given.  In  all  events  a  good  cleansing  should  begin  the  treatment.  Mist, 
rhei  et  soda  in  teaspoonful  doses  can  be  given  several  times  to  cleanse  the 
gastro-intestinal  tract.  Several  hours  after  the  laxative  has  been  given  the 
rectum  and  colon  should  be  flushed  with  hot  water  containing  a  teaspoonful 
of  salt  to  each  pint.  The  temperature  of  the  saline  solution  should  be  about 
110°  F. 

Bismuth  in  3  to  10-grain  doses,  repeated  every  two  hours,  is  our  best 
remedy. 

R  Mist,  creta 2  ounces 

One  teaspoonful  every  two  hours,  is  also  valuable. 

Diet. — Stop  all  milk.  Give  whey  and  rice  water  thickened  with  potato 
flour  or  wheat  flour.  Give  the  white  of  egg  several  times  a  day ;  also  cocoa 
and  water. 

For  Thirst. — Give  5  to  10  drops  of  diluted  hydrochloric  acid  in  a  tum- 
blerful of  boiled  water  (sterilized).     This  can  be  given  ad  libitum. 

Diluted  phosphoric  acid,  20  drops  to  a  tumblerful  of  sweetened  water, 
is  a  pleasant  drink  during  fever.    It  is  also  stimulating. 

The  following  charts  were  kindly  furnished  to  me  by  Dr.  William  H. 
Guilfoy,  Chief  of  the  Bureau  of  Statistics,  Health  Department,  City  of 
New  York: — 


278 


DISEASES  OF  THE  INTESTINES. 


DIARRHCEA. 


279 


280 


DISEASES  OF  THE  INTESTINES. 


^  ^'  »  ^  9 

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y.      5      ;^      s     "3 


DYSENTERY. 


281 


Dysextery   (Ileo-colitis). 

The  lower  portion  of  the  intestine  is  frequently  the  seat  of  an  infection 
by  pathogenic  bacteria. 

Pathology. — As  this  condition  frequently  follows  severe  milk  infection, 
the  pathogenic  lesions  are  necessarily  the  same,  although  in  a  more  ag- 
gravated form.  In  addition  to  the  hyper<smia  of  the  mucous  membrane 
there  may  be  a  small  hemorrhage  in  the  mucosa  or  sub  mucosa.  The  mucous 
membrane  is  very  deeply  jjigmented,  frequently  being  of  a  purplish  line. 


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Fig.  72. — Bacillary  Diphtlioiia  of  the  Colon  or  Diphtheritic  Colitis,  a, 
Necrotic  tissue  containing  bacilli,  b,  Gland  with  necrotic  epithelium,  d, 
Connective  tissue,  e.  Degenerated  and  exfoliated  epithelial  cells,  f,  Bacilli 
in  the  lumen  of  the  gland,  g,  Bacilliary  deposit  beneath  the  epithelium. 
h,  Nests  of  bacilli  in  the  connective  tissue.     X  300.      (Ziegler. ) 

The  solitary  lymph  follicles  along  the  colon  are  swollen.  The  discharge  of 
mucus  is  tinged  with  blood,  and  not  infrequently  the  amceba  coll  described 
by  Losch,  or  known  as  the  amoeba  dysenterice,  described  l)y  Councilman  and 
Lafleur,  can  be  found.  "It  is  a  unicellular,  protoplasmic,  motile  organism 
from  10  to  20  micro-millimeters  in  diameter,  and  consists  of  a  clear  outer 
zone  (ectcsarc)  and  a  granular  inner  zone  (endosarc).  containing  a  nucleus 
and  one  or  more  vacuoles."  ]\rulti]ile  abscesses  are  frequently  found.  "The 
ulcer  first  begins  as  a  small  papule,  the  upper  part  of  which  sloughs  off, 
leaving  a  grayish-yellow  ulcerating  surface." 

AmcEUc  Dysentery.^ — Five  cases  are  reported.  The  diagnosis  was  based  upon 
the  findng  of  motile  amcebte  containing  red  blood-eorpusdes.  The  cases  were 
moderate  in  intensHy.  The  age  of  the  children  was  2  to  5  years.  Four  were 
boys.      They  came  under  observation  at  the  dispensary. 

'Amberg:      Bulletin  Johns  Hopkins  Hospital.  DcccuiIxm-.  1901. 


282 


DISEASES  OF  THE  INTESTINES. 


Little  fever  was  present.  The  stools  varied  in  frequency  from  four  to  twenty- 
four.  Only  one  complained  of  much  pain.  In  two  cases  prolapsus  recti  occurred. 
No  abscess  of  liver  was  found.  The  reaction  of  the  fteces  was  mostly  alkaline. 
They  were  offensive,  liquid  or  solid,  and  accompanied  by  bloody  mucus.  The 
amoeba  may  be  found  only  on  repeated  examination.  If  in  the  passages  of  a  child 
Charcot-Leyden  crystals  are  found,  amoebic  dysentery  should  be  considered.  The 
blood  picture  varied  greatly.  A  leucocytosis  (13,800  to  27,000)  existed  in  every 
case  when  first  examined. 


Fig.   73. — Croupous  Enteritis,   Diphtheritic  Colitis,  two-thirds 
natural  size.      (Langerhans.) 


Diphtheritic  dysentery,  sometimes  known  as  the  croupous  variety,  is 
a  catarrhal  form  of  this  same  condition  previously  described,  in  which  the 
infection  can  be  traced  to  an  invasion  of  the  Klebs-Loeflfler  bacillus.  The 
ulcerations  are  covered  with  a  pseudo-membrane,  and  the  pathogenic  con- 
ditions are  as  previously  described. 

Bacteriology.^ — There  are  two  groups  of  bacilli  which  are  responsible 
for  the  development  of  various  types  of  epidemic  dysentery, 

1.  The  true  Shiga  group. 

2.  Group  of  mannite  fermenters. 

The  latter  group  is  divided  into  two  types; — 

(a)  Fermenting  mannite  alone  in  peptone  solution, 

(h)  Fermenting  maltose   and   saccharose. 


*  The  Journal  of  Medical  Research,  vol.  xi,  No,  2,  May,  1904. 


DYSENTERY. 


283 


Park,  Collins,  and  Goodwin  believe  that  it  is  more  practical  to  divide 
the  bacilli,  having  the  characteristics  of  the  bacillus  isolated  by  Shiga,  and 
call  them  dysentery  bacilli.  The  other  two  groups  resemble  more  closely 
the  colon  group,  in  that  they  produce  indol  and  have  a  greater  range  of 
activity  in  fermenting  carbohydrates,  hence  they  are  called  para-dysentery. 
Park  believes  that  the  prefix  para  will  distinguish  that  form  of  dysentery 
occasionally  seen  in  epidemics  of  the  milder  type. 

When  a  case  of  dysentery  is  found  in  a  family  it  should  immediately 
be  isolated.  The  infection  can  no  doubt  be  disseminated  through  the  alvine 
discharges. 

According  to  a  statement  of  Dr.  W.  H.  Park  to  the  author,  the  Shiga 
bacillus  is  present  in  all  the  stools  found  in  New  York  City  which  contain 
blood  and  mucus. 

The  following  case  attended  by  me  in  the  family  of  Dr.  J.  Morgen- 
Btem  will  serve  to  illustrate  the  character  of  dysentery  as  seen  in  New 
York  City :— 

Case  I. —  (a)  A  child  about  4  years  old  was  taken  sick  after  an  imprudent 
diet,  with  bloody  stools  and  general  symptoms  of  dysentery.  There  were  the  usual 
gastric  disturbances.  After  a  careful  diet  and  intestinal  astringents,  such  as  bis- 
muth and  chalk  mixture,  the  chikl  recovered. 

(5)  Several  days  later  a  female  infant  in  the  same  family,  13  months  old,  was 
suddenly  attacked  with  diarrhoea.     The  infant  had  from  ten  to  thirty  evacuations  a 


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Pig.  74. — Dysentery.    Baby  M.,  Thirteen  Months  Old.     Seen  Fourth  Day  of 
Illness.     Serum  Injected.      (Original.) 


284  DISEASES  OF  THE  INTESTINES. 

day.  \Yhen  I  first  saw  the  child  the  stools  contained  blood  for  the  past  four  days. 
The  child  had  been  perfectly  well  during  the  summer.  Was  breast-fed  until 
September.     Since  weaning  there  has  been  more  or  less  gastrointestinal  trouble. 

Treatmetit. — The  usual  astringents,  such  as  bismuth  and  chalk  mixture,  were 
tried  Avith  little  or  no  success.  High  colon  flushings  of  starch  water  and  a  weak 
solution  of  nitrate  of  silver  were  tried  with  no  benefit  whatsoever.  The  bloody 
stools  continued  and  the  doctor  reported  that  there  was  more  tenesmus,  also  a  pro- 
lapse of  the  rectum.  I  discontinued  the  colon  flushings  and  injected  20  cubic  centi- 
meters of  anti-dysenteric  serum. i  Decided  improvement  Avas  noticed  after  the 
serum  injection.  Two  days  later  the  stools  decreased  in  number  and  there  was  no 
more  evidence  of  blood. 

Four  days  after  the  injection  the  bowels  did  not  move  for  twenty-four  hours. 
The  appetite  improved  and  the  child  convalesced.  I  ordered  some  iron  internally  as 
an  astringent  and  restorative.  A  careful  diet  was  ordered  of  cocoa  with  diluted  milk, 
rice  and  gelatine  pudding. 

Case  II. — A  child  of  Dr.  'SI.,  eighteen  months  old,  was  seen  by  me  in  August 
of  1903.  The  family  was  at  Long  Branch.  The  following  history  was  given.  There 
was  vomiting  and  diarrhoea,  great  prostration,  loss  of  appetite,  and  extreme  thirst. 
The  stools  contained  blood  and  mucus.  There  was  severe  tenesmus.  The  child  had 
stools  as  frequently  as  every  five  or  ten  minvites.  The  pulse  was  very  small  and 
thready.  The  heart  sounds  were  feeble.  The  temperature  in  rectum,  lOP  F.  The 
diagnosis  of  dysentery  was  made. 

Treatment. — The  rectum  and  colon  were  cleansed  witli  a  pint  of  starch  water, 
to  which  a  half-teaspoonful  of  alum  was  added.  Two  teaspoonfuls  of  castor-oil  were 
given  by  mouth. 

Milk  was  stopped  and  whey  was  ordered.  Twelve  hours  later  the  child  was 
again  seen,  and  as  there  was  no  improvement  suppositories  containing  the  following 
were  ordered : — 

R  Argent,    nitrat 1  grain 

Olcoresin  terebinthin    10  grains 

Cocoa  butter   2  drachms 

M.  and  divide  into  suppositories  No.  x. 

Sig. :     One  suppository  every  three  hours. 

Twelve  hours  after  the  above  treatment  was  begun,  the  diarrhoea  still  persisted, 
and  the  exhaustion  and  heart  weakness  were  very  alarming.  I  injected  10  cubic 
centimeters  of  anti-dysenteric  serinn  (Harris).  This  injection  was  given  into  the 
connective  tissue  of  the  abdomen.  The  child  improved  rapidly,  and  I  believe  the 
serum  aided  the  recovery.  Elixir  of  calisaya  and  wine  were  given,  in  addition  to 
coffee,  as  stimulants  during  illness. 

Symptoms. — The  attack  is  usually  ushered  in  with  diarrhoea.  There 
is  also  considerable  straining  with  each  stool.  At  first  the  stools  contain 
particles  of  faeces,  and  as  the  disease  progresses  they  become  more  liquid 
and  contain  mucus  and  blood.  Some  authors  describe  the  stool  as  con- 
tainin<r  shreds  that  resemlile  the  Avashin<xs  of  raw  meat.     The  face  shows 


1  For  the   serum   I   am   indebted  to  Dr.   William   II.   Park,   of   the  New   York 
Health  Department. 


DYSENTERY".  285 

a  very  anxious  expression.  There  is  extreme  pallor.  The  child  appears 
prostrated.  The  pulse  is  accelerated  and  very  feeble.  The  abdomen  is 
distended^  especially  over  the  colon.  Vomiting  is  a  rare  symptom.  Unless 
treatment  is  rapidly  instituted  the  child  will  fail  in  strength  and  may  die. 
Such  children  usually  sleep  with  the  eyes  half  open  and  show  evidences 
of  collapse.  The  rectum  may  protrude,  especially  when  there  is  a  distinct 
relaxation  of  these  parts.  Cold,  clammy  perspiration  is  usually  found, 
especially  on  the  head.  -  The  extremities  are  cold.  Convulsions  appear  in 
the  severer  forms  of  dysentery.  In  the  diphtheritic  variety  the  temperature 
and  pulse  resemlile  a  case  of  true  diphtheria.  The  stool,  in  addition  to 
mucus  and  blood,  may  have  particles  of  pseudo-membrane.  Toxjemia  can 
usually  be  seen  by  its  effect  on  the  heart  and  pulse.  The  urine  may  contain 
albumin.  Where  the  toxaemia  progresses,  convulsions  may  set  in  and  death 
result  from  cardiac  paralysis. 

Diagnosis. — The  bloody  mucus  and  watery  stools  seen  in  this  con- 
dition, associated  with  tenesmus,  will  usually  aid  in  eliminating  acute 
milk  infection.  In  gastro-enteritis  and  entero-colitis  there  is  usually  a 
greenish  spinach-like  stool,  or  a  brown  muddy  stool  having  a  very  fcetid 
odor.  The  stools  in  dysentery  are  smaller  in  quantity.  Both  the  diph- 
theritic and  the  amoebic  forms  of  dysentery  are  rare  in  children. 

Prognosis. — If  this  disease  is  epidemic,  or  if  it  occurs  in  children 
having  bad  sanitary  surroundings/then  the  prognosis  is  bad.  The  dura- 
tion of  an  acute  attack  usually  lasts  about  five  or  six  days.  The  prognosis 
is  good  when  the  diarrhcea  and  blood  gradually  disappear.  The  main 
point  to  remember  is  that  the  heart  must  be  sustained  by  proper  nutrition, 
and  we  should  try  to  counteract  the  toxemia  by  proper  stimulation. 

Treatment. — The  same  hygienic  measures  described  in  the  chapter  on 
"Acute  Milk  Infection"  apply  equally  as  well  here.  Impress  the  mother 
or  nurse  that  unless  she  carries  out  the  directions  minutely,  the  child  has 
little  chance  of  recovery. 

Dieteiic  Treatment. — The  dietetic  management  will  consist  in  leaving 
out  milk.  AVhey,  barley  water,  rice  water,  or  toast  water  may  be  given. 
!^^utton  broth  thickened  with  rice  may  be  given  to  an  older  child.  Whisky 
and  water  should  be  given  from  the  beginning.  It  is  not  too  much  to  give 
2  to  4  ounces  of  whisky  per  day.  The  physician  should  order  the  amount 
of  whisky  by  telling  the  mother  or  nurse  to  give  V2  drachm  or  more  well 
diluted  with  barley  or  rice  water,  every  half-hour. 

Coffee  is  a  valuable  cardiac  stimulant.    Champagne  may  also  be  given. 

Local  Treatment. — The  physician  will  be  most  successful  who  places 
liis  patient  in  bed,  regulates  the  diet,  cleanses  the  intestinal  tract,  and 
relieves  the  tenesmus  by  local  treatment.  The  heart  should  be  supported. 
The  strength  must  be  sustained  with  nutrition  and  the  flushing  of  the  bowel 
should  be  performed  as  soon  as  possible  after  a  stool  is  evacuated. 


286  DISEASES  OF  THE  INTESTINES. 

Warm  chamomile  tea  should  be  used  to  cleanse  the  colon  and  rectum. 
This  should  be  injected  at  a  temperature  of  110°  to  115°  F.,  with  the  aid 
of  a  small  rubber  catheter.  This  can  be  followed  by  an  injection  of  1 
ounce  of  sterile  water  containing  2  grains  of  nitrate  of  silver.  Very  bland 
injections,  such  as 

IJ  Raw  starch 1  teaspoonful 

Chamomile  tea 1  quart 

Laudanum 10  drops 

injected  at  a  temperature  of  100°  F.,  will  soothe  the  rectum  and  frequently 
relieve  tenesmus.  I  have  successfully  treated  dysentery  cases  with  the 
following : — 

IJ  Argentum  nitrate 6  grains 

Oleo  resin  terebinthinse 12  grains 

Extract  of  belladonna 6  grains 

Extract  of  opii  aquosa 1  grain 

Cocoa  butter  q.  s. 

M.     Form  into  twelve  suppositories. 

One  of  these  suppositories  to  be  inserted  into  the  rectum,  and  the 
buttocks  supported  so  that  it  is  retained  at  least  fifteen  minutes.  This  is 
to  be  repeated  three  times  a  day.  Sulpho-carbolate  of  soda,  in  doses  of  5 
to  10  grains,  can  be  used  several  times  a  day.  Bismuth  combined  with 
Dover's  powder  is  frequently  valuable.  An  ice-bag  placed  on  the  abdomen 
in  the  region  of  the  colon  will  sometimes  do  good.  Very  cool  injections 
of  table  salt  and  water  are  sometimes  of  value  when  hot  injections  are  not 
well  borne. 

Serum  Treatment. — The  value  of  serum  treatment  can  best  be  judged 
by  reading  the  clinical  cases  in  this  article. 

Constipation  and  Chronic  Constipation. 

The  bowels  of  an  infant  during  the  nursing  period  should  have  one, 
two,  or  three  evacuations  daily.  Some  children  will  be  quite  normal  with 
one  evacuation  daily.  Older  children  who  partake  of  solid  food  suffer 
more  frequently  with  constipation.  There  are  decided  peculiarities  noted 
in  children  with  reference  to  the  movements  of  the  bowels.  One  child 
will  enjoy  good  health,  have  a  good  appetite,  and  will  gain  in  weight  with 
three  or  four  movements  of  the  bowels  daily.  Another  child  in  equally 
good  health  will  have  but  one  movement  daily.  These  differences  or 
peculiarities  must  be  taken  into  consideration  before  definitely  maintain- 
ing that  our  patient  is  really  constipated.  If  a  child  has  no  movement 
in  twenty-four  hours,  I  usually  suspect  constipation.  When  this  condition 
continues  for  a  period  of  weeks  or  months,  then  we  may  say  chronic  con- 
stipation exists. 


CONSTIPATION.  287 

Causes. — 1.  Dietetic.    2.  Anatomical.     3.  Systemic. 

Dietetic  Caiises. — This  condition  is  most  frequently  met  with  in  bottle- 
fed  infants.  There  are  several  causes  which  generally  contribute  to  stag- 
nant fseces: — 

First, — Cows'  milk  with  its  thick  casein  is  much  more  difficult  to 
digest.  An  excess  of  casein  in  the  food  frequently  induces  constipation. 
In  some  infants  the  moment  we  increase  to  more  than  1  per  cent,  of 
casein,  constipation  will  result.  A  deficiency  in  the  amount  of  sugar  will 
frequently  cause  constipation.  This  applies  to  breast-fed  infants  as  well 
as  to  bottle-fed  infants. 

Second. — The  application  of  heat  to  milk,  especially  when  sterilization 
is  continued,  results  in  constipation. 

Third. — When  milk  contains  a  deficiency  of  fat  the  excess  of  casein 
will  stagnate. 

Fourth. — The  infant  is  frequently  dyspeptic  or  rachitic,  and  in  this 
latter  condition  the  peptic  and  intestinal  glands  do  not  perform  their  nor- 
mal functions;  this  absence  of  intestinal  glandular  secretions  is  one  of  the 
main  factors  resulting  in  constipation. 

Fifth. — When  water  is  not  given  to  an  infant  it  frequently  suffers 
with  constipation. 

Anatomical  Changes. — Jacobi  says:  "The  embryonic  intestine  is 
formed  in  separate  divisions.  There  is  no  ascending  colon  up  to  the  fourth 
or  fifth  month  of  foetal  life.  It  is  very  short  in  the  mature  new-born. 
Despite  this,  the  large  intestine  of  the  mature  foetus  is  longer  in  propor- 
tion than  that  of  the  adult.  It  is  three  times  as  long  as  the  body  of  the 
foetus,  while  it  is  only  twice  as  long  in  the  adult.  There  is  the  same  dis- 
proportion with  regard  to  the  length  of  the  small  intestine.  The  small 
intestine  of  the  foetus  in  the  ninth  month  is  twelve  times  as  long  as  its 
body.  The  small  intestine  of  the  adult  is  only  eight  times  as  long  as  the 
body." 

The  colon  ascendens  being  very  short,  the  surplus  of  length,  partic- 
ularly as  the  transverse  colon  also  is  not  long,  belongs  to  the  descending 
colon,  and  especially  to  the  sigmoid  flexure.  Drandt  found  it  between  8 
and  24  centimeters  in  length,  averaging  from  14  to  20  centimeters.  Jacobi 
saw  a  ease  in  which  it  was  30  centimeters  long. 

xVs  the  pelvis  is  very  narrow,  the  great  length  of  the  lower  part  of  the 
large  intestine  is  the  cause  of  multi2)le  flexures,  instead  of  the  single  sig- 
moid flexure  of  the  adult.  Tlius  it  is  that,  now  and  then,  two  or  even 
three  flexures  are  found,  and  to  such  an  extent  that  one  of  them  may  be 
found  to  extend  as  far  as  the  right  side  of  the  pelvis.  Cruveilhier  and 
Sappey  speak  of  this  position  of  llu'  lower  part  of  the  intestine  in  the 
right  side  of  tlie  pelvis  as  an  anoninly.  ITuguier  finds  it  on  the  right  side 
of  the  body  in  the  majority  of  cases.     Others  only  occasionally,  although 


288  DISEASES  OF  THE  INTESTINES. 

they  admit  the  great  length  of  the  sigmoid  flexure.  In  common  with 
Huguier,  who  even  proposes  to  operate  for  artificial  anus  in  the  right  side, 
Jacobi  found  one  of  the  flexures  on  the  right  side  many  times. 

The  great  length  of  the  large  intestine  and  the  multiplicity  of  its 
flexures  are  of  great  functional  importance.  At  all  events,  they  retard  the 
movement  of  the  intestinal  contents,  facilitate  the  absorption  of  fluids,  and 
thus  the  faeces  are  rendered  solid.  When  this  length  is  developed  to  an 
unusual  extent,  constipation  is  the  natural  result.  In  the  American  Jour- 
nal of  Obstetrics,  August,  1869,  Jacobi  described  two  cases  in  which  the 
descending  colon  was  so  long  that  the  diagnosis  of  imperforate  rectum  was 
made.  In  one  of  them  the  operation  for  artificial  anus  was  performed.^ 
"Such  cases  and  such  errors  are  certainly  very  rare;  still  there  are  those  in 
which  normal  anatomical  conditions  will  lead  to  incidents  of  great  patho- 
logical importance." 

Eecords  of  post-mortem  observations  made  by  Dr.  T.  C.  Martin^  prove 
that  the  muscular  development  of  the  adult  rectum  and  lower  sigmoid  is 
plainly  apparent,  and  that  a  deficient  muscularity  is  observable  in  the  in- 
fant specimens.  In  the  infant  gut  the  intrinsic  power  of  peristalsis  is  not 
present  in  that  degree  necessary  to  it  as  a  competent  expulsory  factor. 

The  meso-peritoneum  of  these  parts  in  the  adult  is,  relatively,  very 
considerably  shorter  than  that  in  the  infant.  The  adult  gut  is  slightly 
tortuous;  that  of  the  infant  is  much  angulated.  Mobility  and  angulation 
of  the  infant  gut  conspire  to  obstruct  the  passage  of  formed  faeces. 

The  rectal  valve  appears  to  bear  the  same  proportion  to  the  gut  in  both 
adult  and  infant,  but  when  the  difference  in  muscular  development  in  the 
two  is  noticed  the  disproportionate  great  resistance  of  the  valve  in  the  infant 
rectum  becomes  an  obvious  fact. 

Systemic  Causes. — Incomplete  peristalsis,  such  as  exists  in  the  rachitic 
debility  of  the  muscular  layer,  in  the  muscular  debility  dependent  upon 
sedentary  habits  and  peritonitis,  intestinal  atrophy,  and  hydrocephalus. 

Mechanical  Obstruction. — Cystic  tumors  in  the  intestine.  There  is, 
further,  intussusception  and  twisting  of  the  intestine,  incarcerated  hernia, 
even  umbilical  hernia,  hardened  faeces,  and  imperforations. 

In  all  these  cases  the  diagnosis  should  not  be  made  without  manual 
examination.  In  most  of  the  cases  the  abdomen  is  inflated,  though  it  be 
painless.  The  faeces  come  away  in  small,  hard  lumps  or  in  large  masses. 
The  liver  and  spleen  are  displaced.  The  liver  may  be  so  turned  that  a  part 
of  its  posterior  surface  comes  forward.    The  abdominal  veins  are  enlarged 


*  For  a  detailed  description  see  "Concetti  Archiv  fUr  Kinderheilkunde,"  vol. 
xxvii,  1899. 

*"A  Study  of  the  Difficulties  of  Defecation  in  Infants,"  by  Dr.  T.  C.  Martin, 
read  at  the  forty-eighth  annual  meeting  of  the  American  Medical  Association,  June 
4,  1897. 


CONSTIPATION. 


289 


Fig.  7.1. — Ascendinsf  Position. 


Tier.  70. — Ascendinjf  Position. 


Fi;'.  77.- — Transverse  Position. 


Fi".  78. — Transverse  Position. 


FifT.  70. — Dosfeiuling  Position. 


Tiff.  SO. — Dcsoondinji  Position. 


Illustrations  of  tlic  \aiinus  types  of  ahiioriiialil y  of  the  sigmoid 
flexure,  wliich  are  the  source  <,i  luihitual  ((Hislifiatinn  in  Infants.  (After 
jMarfan  &  Neter.) 


290  DISEASES  OF  THE  INTESTINES. 

to  such  an  extent  that  they  form  circles  around  the  umbilicus,  similar  to 
what  is  seen  in  hepatic  cirrhosis.  These  children  lose  their  appetite,  some- 
times vomit,  and  the  irritation  produced'  by  the  hardened  masses  in  the 
intestinal  canal  may  be  such  as  to  finally  result  in  diarrhoea,  which,  how- 
ever, is  not  always  sufficient  to  empty  the  tract. 

There  is,  besides,  an  apparent  constipation,  which  should  not  be  mis- 
taken for  any  of  the  above  varieties.  Now  and  then  a  child  will  appear  to 
be  constipated,  have  a  movement  every  two  or  three  days,  and  at  the  same 
time  the  amount  of  faeces  discharged  is  very  small.  This  apparent  con- 
stipation is  seen  in  very  young  infants  rather  than  in  those  of  more  ad- 
vanced age.  Such  children  are  emaciated,  sometimes  atrophic.  They  ap- 
pear to  be  constipated  because  of  lack  of  food,  and  not  infrequently  this 
apparent  constipation  is  relieved  by  a  sufficient  amount  of  nourishment. 

As  there  is  frequently  a  large  excess  of  acid  in  the  intestine,  magnesia 
with  or  without  rhubarb,  will  frequently  relieve  the  acidity  and  cause  a 
movement  of  the  bowels. 

In  the  chapter  on  "Cream"  I  have  already  spoken  of  the  deficiency  of 
fat,  which  is  one  of  the  most  frequent  causes  of  constipation.  Hence,  in 
an  infant  nursing  at  the  breast  it  is  wise  to  give  the  child  a  teaspoonful 
'of  raw  cream  immediately  before  taking  the  breast  to  correct  the  consti- 
pation. Cream  consists  of  so  much  fat  that  in  this  manner  we  add  fat 
directly  to  our  food.  This  is  the  secret  of  success  attained  by  some  authors 
when  they  advise  giving  codliver-oil,  butter,  or  olive-oil  to  very  young 
children.  Each  one  desires  to  remedy  the  deficiency  of  fat  in  his  own  par- 
ticular manner. 


Fig.  81.— Rubber  Bulb  Syringe. 

Symptoms. — In  older  children,  headaches,  restlessness,  and  occasion- 
ally abdominal  pains  are  complained  of.  I  have  frequently  seen  high  tem- 
perature caused  hy  constipation,  which  temperature  disappeared  soon  after 
the  evacuation.  Eestlessness  at  night,  continued  crying  in  young  infants, 
with  the  legs  drawn  up  on  the  abdomen,  and  fretfulness  indicate  colicky 
pains,  frequently  the  result  of  constipation. 

Treatment. — Immediate  Relief  (Removal  of  Scyhala) :  Hardened 
round  balls  or  fragments  of  faeces  will  frequently  be  caused  when  the  stool 
remains  very  long  in  the  colon,  or  when  the  sigmoid  flexure  has  an  unusual 
length;  in  such  instances  the  injection  of  either  ^/j  pint  of  lukewarm 
sweet  oil  or  glycerine  will  soften  these  scybala  and  aid  in  their  expulsion. 


CONSTIPATION. 


291 


At  times  these  balls  will  be  as  hard  as  marbles,  and  may  require  the  aid 

of  a  small  scoop  (the  handle  of  a  teaspoon  will  do)  to  aid  in  their  removal. 

Enema. — A  rule  that  I  have  always  followed,  and  one  that  I  lay 

stress  upon,  is  never  to  allow  a  child  to  retire  at  night  without  having  had 


Fig.  82. — Irrigator,  with  Tube  Attached  and  Hard  Rubber  Points. 


a  movement  of  the  bowels  during  the  day.  The  reason  for  this  is  plain; 
not  only  will  the  accumulated  faeces  and  gas  cause  flatulence,  colic,  and 
uneasiness,  but  this  constant  distention  of  the  bowels  will  dilate  the  intes- 
tines to  such  a  degree  that  frequently  a  permanent  pendulous  belly  remains. 
My  plan  is  to  order  an  injection  of  a  half-tumbler  of  ordinary  glyc- 
erine mixed  with  a  pint  of  warm  water — temperature,  100°   F. — and  to 


Fig.  83. — Soft  Rublxsi   ivev-ia,!  Tube  for  Irrigating  the  Colon. 

allow  this  quantity  to  flow  into  the  rectum  by  using  a  fountain-syringe,  the 
end  of  which  has  the  smallest  infants'  rectal  nozzle.  In  this  manner  we 
have  a  rapid  emptying  of  the  rectum  and  colon,  and  can  be  assured  of  tem- 
porary and,  possibly,  permanent  relief.  It  is  not  absolutely  vital  to  use 
glycerine  and  water,  for  a  similar  result  can  be  obtained  if  we  make  soap- 
water  by  rubbing  up  Castile  or  glycerine  soap  in  a  pint  of  warm  water. 


292  DISEASES  OF  THE  INTESTINES. 

Continued  Use  of  Enema. — In  obstinate  cases  it  is  well  to  slip  a  soft- 
rubber  rectal  tube  over  the  nozzle,  and,  having  anointed  the  rubber  tul)e 
with  vaseline  or  glycerine,  the  same  can  be  pushed  slowly  into  the  rectum, 
tlien  allow  about  half  a  pint  of  water  to  flow  into  the  rectum,  which  will 
distend  it  gradually,  and,  by  simply  pushing  the  tube  farther  into  the  colon, 
we  can  allow  the  balance  of  1  pint  or  more  to  flow  directly  into  the  colon. 
The  continued  use  (daily)  of  these  enemas  is  not  fraught  with  danger; 
on  the  contrary,  these  rectal  injections  can  be  used  for  months.  In  safe 
hands,  if  the  mother  or  nurse  is  intelligent,  there  should  be  not  only  no 
injury,  but  positive  good,  from  their  continued  use. 

Use  of  Cold  Water.— The  injection  of  cold  water  through  a  soft  flexible 
catheter  or  with  the  aid  of  a  rectal  tube  acts  as  an  excellent  tonic.  This 
injection  repeated  once  a  day  should  be  practiced  for  a  long  time.  If  we 
can  teach  the  child  to  retain  the  cold  water  so  much  the  better.  The  stim- 
ulus of  the  cold  water  is  especially  valuable  when  constipation  is'  due  to 
chronic  colitis  associated  with  catarrh. 

Suppositories. — Among  those  most  commonly  used  are  suppositories 
of  the  glycerine  and  gluten  type.^  Most  suppositories  in  the  market  are 
entirely  too  large,  and  frequently  must  be  cut  into  halves  and  quarters. 
The  suppository  made  by  John  A.  Wyeth  &  Co.  has  served  the  author  very 
well.  It  should  be  distinctly  understood  that  a  suppository  is  to  be  used 
in  the  evening  for  the  same  relief  as  we  desire  from  the  injection  or  enema 
previously  mentioned.  Neither  the  suppository  nor  the  injection  should  be 
used  with  the  idea  of  curing  a  constipation. 

Hygienic  Treatment. — We  should  insist  on  proper  ventilation  of  a 
child's  sleeping-room  at  night,  and  it  is,  therefore,  advised  that  the  window 
be  left  open  a  few  inches.  This  is  not  fraught  w!th  danger;  on  the  con- 
trary, it  is  healthful  and  beneficial  to  allow  children  to  play  in  the  open 
air  all  day,  and  naturally  to  shut  them  up  in  poorly  ventilated  apartments 
at  night  is  simply  inviting  both  throit  and  lung  trouble.  In  addition  to 
proper  ventilation,  bathing  in  cool  water  or  lukewarm  water,  followed  by 
an  abdominal  spray  or  a  douche  directed  against  the  stomach  and  bowels, 
will  be  found  advantageous  in  the  correction  of  this  ailment.  Following  the 
bath,  friction  with  a  good,  coarse,  Turkish  towel  will  be  found  useful.  My 
preference  has  always  been  for  a  lukewarm  bath,  followed  by  a  cold  douche 
for  a  few  moments,  every  morning,  and  then  to  have  the  child  properly 
rul)bed  until  the  skin  is  reddened  with  a  Turkish  towel,  followed  by  massage 
witli  oil  or  vaseline. 

Mechanical  Treatment. — Exercise:  What  nuissagc  is  for  a  young  in- 
fant exercise  is  for  an  older  child.  Thus,  it  is  apparent  that  atonic  con- 
ditions can  best  be  relieved  bv  com])iuing  tlie  dietetic  and  medicinal  treat- 


'  CJluten  suiiiiusitoiic's  arc  made  Ly  tlie  Ik'altli   Tood  Company,  of  New  York 
City. 


CONSTirATION.  293 

mcnt  with  ont-of-rloor  exercise.  Children  should  be  permitted  to  romp 
about  and  walk  and  play  out  of  doors,  but  not  to  a  point  approaching 
fatigue.  Older  children  will  find  bicycle  exercise  or  horseback  riding  de- 
cidedly beneficial.  It  is  important,  however,  to  regulate  the  amount  of 
such  exercise,  and  thus  it  is  the  physician's  duty  to  tell  the  mother  or  nurse 
just  how  long  a  child  should  be  permitted  to  exercise.  It  would  seem  that 
one-half  hour  twice  a  day  is  ample  to  arrive  at  beneficial  results.  Over- 
indulgence in  such  sports  wall  frequently  result  in  rupture  and  produce 
heart  strain.  In  cardiac  lesions,  in  asthmatic  conditions,  if  children  suifer 
with  whooping-cough,  and  in  tuberculous  conditions,  such  exercises  must 
not  be  allowed. 

Massage. — Continued  kneading  of  the  abdomen  with  the  aid  of  vase- 
line or  oil  will  be  found  serviceable,  and,  if  properly  done,  will  provoke  an 
action  of  the  bowel.  Thus  it  is  that  rubbing  the  abdomen  with  castor-oil 
has  frequently  been  recommended  in  the  treatment  of  constipation;  the 
eliect  supposed  to  be  due  to  the  castor-oil  is,  in  reality,  due  to  the  massage, 
and  to  nothing  else.  When  vibratory  massage  is  used,  it  should  be  con- 
tinued from  five  to  ten  minutes  every  day  for  one  month.  This  will  cer- 
tainly aid  and  stimulate  peristalsis,  and  ultimately  tone  the  muscles  and 
cure  the  constipation. 

Method  of  Performing  Massage. — The  hands  are  gently  placed  on  the 
right  side  of  the  abdomen  at  about  the  ileo-cascal  region.  Gentle  pressure 
should  be  made,  otherwise  the  abdominal  muscles  will  be  tense.  Com- 
mence each  stroke  of  the  massage  with  gentle  pressure  and  utilize  each 
inspiration  for  firmer  and  firmer  jjressure.  The  same  method  of  palpation 
which  is  employed  for  the  diagnosis  of  a  tumor  in  the  deep  tissues  should 
be  employed.  After  firm  pressure  has  been  made,  we  can  then  gradually 
massage  by  a  rotary  movement,  first  the  ascending  colon,  continue  over 
the  transverse  colon,  and  finally  over  the  descending  colon  and  rectum. 
Hardened  scybala  can  frequently  be  felt  in  the  region  of  the  ca2cum  and  can 
be  propelled  by  this  mechanical  treatment  through  the  various  portions  of 
the  colon  to  the  rectum. 

Length  of  Time  Bcquired  for  Each  Massage. — From  five  to  ten  min- 
utes every  morning  and  evening  can  be  continued  for  several  weeks.  If 
improvement  is  noted,  then  less  frequent  treatment  is  required.  To  be 
successful,  several  months  of  treatment  may  be  necessary  in  obstinate  cases. 
We  must  persist  in  stimulating  the  peristaltic  waves  regularly  and  not  be 
disapi)ointed  if  immediate  results  are  not  secured.  My  plan  has  always 
been  to  inform  the  parents  that  I  do  not  expect  any  success  in  a  chronic 
constipation  which  has  persisted  for  months  or  years,  until  six  months  or 
more  have  passed. 

Eleciricity. — This  is  very  valuable  to  stimulate  peristalsis.  The 
faradic,  galvanic,  or  static  current  can  be  used.     For  the  general  practi- 


294  DISEASES  OF  TETE  INTESTINES. 

tioner  the  use  of  the  galvanic  current,  five  to  ten  cells,  is  sufficient.  The 
negative  pole  (cathode)  should  be  applied  in  the  rectum,  and  the  positive 
pole,  which  produces  peristaltic  waves,  should  be  applied  over  the  ascend- 
ing, descending,  and  transverse  colon.  Local  contractions  result  from  the 
negative  pole.  A  gentle  faradic  current  applied  over  the  spine  and  the 
abdomen  will  answer  if  used  for  several  minutes  in  the  absence  of  the 
galvanic  current.  Galvanic  electricity  should  be  used  every  day;  fre- 
quently months  are  required  to  insure  a  cure,  in  conjunction  with  the 
medicinal  and  dietetic  treatment. 

Dietetic  Treatment. — We  have  previously  mentioned  the  value  of 
cream,  and  the  addition  of  water  for  the  treatment  of  constipation.  In 
bottle  babies  it  is  well  to  remember  that  oatmeal  water  and  sago  water  should 
be  used  when  constipation  exists.  Under  no  condition  should  barley  or  rice 
be  given,  as  the  latter  will  simply  increase  the  constipation.  Older  children 
should  be  given  fruit,  baked  apples,  tamarinds,  apricots,  peaches,  prunes, 
grapes,  and  oranges.  Buttermilk  will  be  found  serviceable,  as  well  as 
kumyss,  for  the  relief  of  constipation.  Sugar  (cane  sugar)  will  be  found 
quite  serviceable,  when  added  to  water,  for  the  relief  of  constipation  in 
nursing  or  bottle-fed  babies.  Thus,  a  good  plan  is  to  give  a  small  piece 
of  loaf  sugar  dissolved  in  water  immediately  before  nursing,  and  to  sub- 
stitute and  use  cane  sugar  instead  of  milk  sugar  for  bottle-fed  babies. 

Having  regulated  the  diet  and  excluded  fresh  bread,  cakes,  pies, 
pastries,  macaroni,  and  other  floury  foods,  we  should  insist,  in  children 
over  2  years  of  age,  on  eating  all  green  vegetables  with  the  exception  of 
cabbage,  beans,  turnips,  potatoes,  and  corn.  Thus,  celery,  spinach,  green 
peas,  asparagus,  and  cauliflower  are  recommended. 

A  Drink  of  Water. — From  infancy,  when  the  child  is  but  a  few  days 
old,  we  should  make  it  a  rule  to  give  it  a  drink  of  water;  a  very  small 
infant  during  its  first  week  can  be  given  two  to  three  teaspoonfuls  of 
boiled  water  during  the  day.  A  safe  plan  is  to  give  this  drink  of  water 
when  it  is  not  time  for  feeding,  and  if  the  child  appears  restless. 

Drug  Treatment. — A  great  many  drugs  are  indicated  and  contra- 
indicated  in  the  treatment  of  constipation.  The  intelligent  practitioner 
does  not  desire  merely  one  movement  of  the  bowels,  brought  about  by 
drugs,  but  seeks  rather  to  use  such  therapeutic  measures  as  will  give  a  per- 
manent cure.    My  choice  of  drugs  is  the  following: — 

I^  Ext.  cascara  sagrada  fl 1  ounce 

Glycerine    1  ounce 

M.  Twenty  drops  of  the  above  mixture  in  a  teaspoonful  of  water  throe 
times  a  day,  for  children  about  three  months  old.  At  the  age  of  six  months,  double 
the  dose,  or  40  drops  three  times  a  day.  At  the  age  of  1  year  a  teaspoonful  three 
times  a  day. 


CONSTIPATION.  295 

Another  valuable  preparation  is  malt  extract  with  cascara,  in  tea- 
spoonful  doses,  once  or  twice  a  day. 

My  plan  is  to  give  the  first  dose  in  the  morning  before  the  feeding, 
and  note  the  result.  If  the  bowels  move  by  noon-time  then  I  discontinue 
the  dose  at  noon^  and  give  a  second  dose  in  the  evening.  If,  however,  there 
is  no  effect  by  noon-time,  then  I  continue  my  second  dose,  and  follow  with 
my  third  dose  in  the  evening.  Thus,  it  will  be  apparent  that,  if  one  dose 
answers  for  the  day,  then  we  should  discontinue  the  medicine  for  that  day, 
but  commence  again  on  the  following  day,  and  keep  up  this  form  of  drug 
treatment  until  it  is  apparent  that  the  bowels  are  not  as  sluggish  in  their 
action  as  before.  Another  drug  which  has  been  one  of  my  stand-bys  for 
many  years  is  nux  vomica.  I  give  1  drop  of  the  tincture  of  nux  vomica 
in  a  teaspoonful  of  sweetened  water  three  times  a  day,  for  an  infant  up 
to  1  year  of  age.  Children  of  2  years  I  give  2  drops  three  times  a  day. 
From  3  to  6  years,  3  drops  three  times  a  day.  Six  to  10  years,  4  drops 
three  times  a  day.  Ten  to  15  years  of  age,  5  drops  three  times  a  day.  Nux 
vomica  is  always  to  be  administered  on  an  empty  stomach;  in  other  words, 
before  feeding.  Another  valuable  drug  is  rhubarb  in  the  form  of  the 
aromatic  syrup  of  rhubarb.  From  ^/^  to  1  teaspoonful  once  or  twice  a  day, 
repeated  every  two  days,  will  frequently  afford  relief. 

Powdered  rhubarb  and  magnesia,  given  in  teaspoonful  doses  to  very 
young  children,  is  one  of  the  best  laxatives  and  antifermentatives  that  we 
possess.    It  is  especially  indicated  for  the  relief  of  colic. 

Citrate  of  magnesia,  given  in  wineglassful  doses  to  children  over  1 
year  of  age  once  or  twice  a  day,  can  also  be  recommended. 

In  atonic  conditions  of  the  bowels  depending  on  general  weakness, 
strychnine,  given  in  V200  or  ^/lo^-grain  doses  twice  a  day,  will  be  found 
useful.     This  may  or  may  not  be  com.bined  with  iron. 

The  infusion  of  senna  leaves  is  made  by  boiling  a  heaping  teaspoonful 
of  ordinary  senna  in  a  teacupful  of  boiling  water  for  fifteen  minutes,  strain- 
ing, and  when  cool  adding  1  tablespoon  of  glycerine  to  5  tablespoons  of 
this  infusion  of  senna.  This  quantity  to  be  administered  in  three  doses  at 
intervals  of  four  or  five  hours.  In  some  instances  the  addition  of  syrup  of 
manna  will  be  found  advantageous  in  sweetening  the  infusion  of  senna. 

Phosphate  of  soda,  iu  doses  of  5  to  15  grains,  given  in  milk  with  the 
food,  is  a  mild  and  sure  laxative.  A  pleasant  preparation  sold  in  the  shops 
is  known  as  milk  of  magnesia.  It  is  a  good  antacid  and  laxative  when 
given  in  doses  of  ^/^  to  1  teaspoonful. 

Certain  drugs  should  not  be  given.  Of  these  castor-oil  may  serve  a8  a 
type.  The  constipating  effect  following  the  use  of  castor-oil  is  so  well 
known  that  this  drug  is  indicated  when  we  wish  to  cleanse  the  stomach  and 
bowels  and  remove  stagnant  food,  as,  for  example:  in  fermentative  dys- 
pepsia accompanied  by  diarrhoea.     Thus,  we  not  only  have  an  effective 


296  DISEASES  OF  THE  INTESTINES. 

movement,  but  a  constipating  effect  following  the  same.  The  use  of  drastic 
cathartics — such  as  scammony,  elaterin,  or  podophyllin — should  not  be 
thought  of  in  the  treatment  of  infants  and  children.  Very  rarely  do  I 
use  aloes,  owing  to  its  offensive  taste.  It  is  understood  that  calomel  is  only 
to  be  given  when  we  wish  to  cleanse  and  produce  an  antiseptic  effect  in 
the  intestine;  for  the  treatment  of  constipation  per  se,  calomel  is  entirely 
out  of  place. 

Intestinal  Colic  (Intestinal  Neuralgia:    ENTEiaLGiA). 

Intestinal  colic  consists  of  pain  which  is  paroxysmal  in  character, 
located  in  the  bowel  and  without  evidence  of  inflammation. 

Symptoms. — Colic  is  one  of  the  most  frequent  causes  of  crying  in 
children.  They  not  only  cry  loudly,  but  will  suddenly  shriek,  and  when 
put  to  sleep  will  awaken  with  a  sudden  start,  and  cry  loudly.  The  legs  are 
usually  flexed  or  they  will  move  their  legs  back  and  forth,  or  up  and  down. 
They  will  seem  to  bend  the  body  on  itself.  These  attacks  are  usually  asso- 
ciated with  constipation;  hence,  it  is  a  good  plan,  when  the  child  is  rest- 
less and  utters  a  painful  cry,  to  see  if  the  bowels  have  moved.  It  is  well 
known  that  this  colic  may  be  as  well  associated  with  diarrhcea.  The  origin 
of  all  colic  is  certainly  the  stomach.  When  dyspeptic  conditions,  arising 
from  undigested  particles  of  food  in  the  stomach,  exist,  then  fermentation, 
resulting  in  gas  formation,  is  the  result.  Colic  is  frequently  but  incorrectly 
known  by  the  terms  of  "meteorismus"  or  "tympanites,"  but  in  the  latter 
conditions  the  abdomen  is  greatly  distended,  and  there  is  a  permanent 
enlargement  of  it.  Borborygmus  (rumbling  sounds)  can  usually  be  made 
out,  if  the  ear  is  applied  to  the  abdomen.  The  vast  majority  of  cases  of 
colic  have  their  seat  in  the  intestine,  and  can  be  relieved  very  quickly. 

Causes. — Worms  (ascarides)  have  been  known  to  cause  colic.  When 
there  is  a  general  loss  of  tone  on  the  part  of  the  muscular  layers  in  the  walls 
of  the  intestine,  colic  will  frequently  result.  Jacobi  believes  that  colic  can 
be  caused  by  chronic  peritonitis  resulting  in  adhesions  or  local  changes  in 
the  walls  of  the  intestine  that  will  produce  local  contractions  or  dilatations. 

Excess  of  Sugar. — When  colic  is  caused  by  an  excess  of  sugar,  there 
will  be  considerable  eructations  of  gas,  and,  frequently,  small  quantities  of 
food  will  be  regurgitated. 

The  stools,  when  an  excess  of  sugar  is  given,  are  thin  and  greenish, 
smell  very  acid,  and  usually  produce  a  reddened  excoriation  of  the  buttocks 
around  the  anus. 

When  children  show  a  tendency  to  the  development  of  gas  and  have 
constant  recurring  colic,  my  plan  is  to  discontinue  the  use  of  sugar  until 
such  time  as  this  fermentation  is  absent.  To  sweeten  the  food  I  use  small, 
sacchariDe  tablets,  1  grain  being  ample  to  sweeten  1  pint  of  food.  When 
there  is  a  tendency  to  constipation,  it  is  possible  not  only  to  sweeten  the 


INTESTINAL  COLia  297 

food,  but  also  to  modify  this  constipation  by  adding  1  teaspoonful  of  pure 
glycerine  to  each  bottle  of  food  prepared.  A  teaspoonful  of  malt-extract 
will  sweeten  and  also  relieve  constipation. 

Excess  of  Proteids} — A  careful  observation  of  the  stools  would  easily 
show  whether  the  albuminoids  are  in  excess,  for  they  are  usually  present 
in  the  form  of  curds.  This  condition  is  usually  associated  with  constipa- 
pation,  and  the  indication  would  be  to  cut  down  the  quantity  of  proteid 
administered. 

Undigested  curds  due  to  excess  of  proteids  and  excessive  fats  are  a 
frequent  cause  of  colic.  Irregular  feeding,  too  frequent  or  over-feeding, 
are  the  commoner  causes.  The  majority  of  cases  of  colic  are  seen  in  bottle- 
fed  babies.  This  is  usually  due  to  milk  which  is  too  acid  or  superheated 
milk,  as  in  prolonged  sterilization.  In  the  latter  manner  of  treating  milk 
the  casein  is  rendered  very  difficult  to  digest,  and  frequently  results  in 
intestinal  fermentation,  causing  colic. 

Colic  in  Breast-fed  Babies. — If  colostrum  continues  and  the  milk  does 
not  assume  normal  conditions,  colic  may  result.  Colic  is  frequently  seen 
during  menstruation  of  nursing  women.  Pregnancy  occurring  during  lac- 
tation usually  causes  colic. 

Differential  Diagnosis. — We  must  be  extremely  careful  to  exclude  the 
pain  of  intussusception,  the  pain  from  gall-stones,  the  pain  of  appendicitis, 
or  the  pain  of  a  strangulated  hernia.  The  absence  of  fever,  the  disappear- 
ance of  the  symptoms  by  the  regulation  of  the  diet,  the  flushing  of  the 
colon  to  remove  the  offending  cheesy  dehriSj  will  materially  aid  in  strength- 
ening the  diagnosis. 

Infant  J.,  eleven  months  old,  bottle-fed,  cried  and  suffered  with  pain  from 
one  to  two  hours  after  taking  his  feeding.  The  temperature  was  101°  F.,  rarely 
higher.  The  infant  would  scream  for  a  few  minutes  at  a  time,  then  expel  flatus  per 
rectum,  and  be  apparently  relieved.  He  would  be  cheerful  and  play  for  a  short 
time  when  another  paroxysm  of  pain  would  come  on  and  start  him  screaming  again, 
until  flatus  was  expelled.  Relief  was  immediately  given  when  the  rectum  and 
colon  were  flushed  with  warm  water  to  which  several  ounces  of  glycerine  had  been 
added,  temperature,  115"  F.  Anti-fermentativea,  such  as  rhubarb  and  soda  mixture, 
or  several  grains  of  calcined  magnesia,  invariably  relieved  the  child  and  prevented 
intestinal  fermentation. 

The  treatment  of  colic  is  simple  when  the  cause  is  known.  The  quick- 
est method  of  relieving  colic  is  to  give  an  enema  of  soap  and  water  or  of 
warm  chamomile  tea.  I  usually  take  an  ounce  of  German  chamomile 
flowers  and  steep  them  in  a  quart  of  boiling  water  from  ten  to  fifteen  min- 
utes, then  strain.  The  injection  is  to  be  given  in  the  same  manner  as 
has  been  described  in  detail  in  the  chapter  on  '*Constipation."    My  method 

'  Read  also  article  on  "Proteid  Indigestion,"  in  chapter  on  "Breast  Feeding," 
Part  UL 


298  DISEASES  OF  THE  mTESTINBS. 

is  to  allow  1  or  2  pints  of  chamomile  tea  at  a  temperature  of  100°  to  110° 
F.  (no  hotter)  to  flow  slowly  into  the  rectum,  and  by  all  means  the  colon. 
When  the  colon  is  thoroughly  flushed  with  this  warm  tea,  and  emptied  of 
its  faeces,  it  is  usual  for  the  attack  of  colic  to  cease.  In  addition  to  washing 
the  colon,  it  is  a  good  plan  to  apply  a  small  bag  of  either  chamomile  flowers 
or  slippery  elm  bark,  or  ground  flaxseed  meal.  To  do  this,  I  make  a  bag 
of  cheese-cloth,  capable  of  holding  from  1  to  2  ounces,  and  then  fill  it  with 
one  of  the  above-mentioned  ingredients;  sew  the  bag  shut  when  filled,  and 
heat  it  before  applying  to  the  abdomen.  Several  of  these  bags  can  be  made 
and  kept  in  readiness,  so  that  they  can  be  applied  quickly.  It  is  a  good 
plan  to  have  one  heating  on  the  stove,  while  another  is  on  the  abdomen. 
These  little  bags  are  very  soothing,  and  we  are  frequently  rewarded  by 
having  the  infant  not  only  expel  wind  shortly  after  they  are  applied,  but 
also  fall  asleep. 

Massage. — During  an  attack  of  colic  gentle  massage  with  warm  sweet- 
oil  or  melted  vaseline  or  lard  will  certainly  be  very  comforting  to  the  child. 
My  plan  is  to  take  a  bottle  of  oil,  warm  it  by  placing  it  in  a  kettle  of  warm 
water,  and  then  to  pour  it  on  the  abdomen.  The  distended  abdomen  should 
then  be  thoroughly  kneaded  until  the  gas  is  expelled.  Then  the  warm  appli- 
cations mentioned  above  can  be  applied. 

Drug  Treatment. — If  the  colic  originated  from  a  fermentative  dys- 
pepsia, then  treatment  must  be  directed  to  the  stomach.  For  this  purpose 
antifermentatives,  like  the  mistura  rhei  et  sodse,  should  be  given  in  doses 
of  V2  to  1  teaspoonful,  diluted  with  water,  every  two  or  three  hours  until 
there  is  a  thorough  evacuation.  Very  good  results  will  be  found,  after  the 
bowel  has  been  cleaned  with  the  quart  of  chamomile  tea  previously  men- 
tioned, by  administering  from  5  to  10  grains  of  bismuth;  I  prefer  to  use 
betanaphtol  or  the  subnitrate ;  y^-grain  doses  of  resorcin  will  also  be  found 
useful.  Paregoric  in  doses  of  15  drops  to  ^/j  teaspoonful  should  be  admin- 
istered with  great  caution  to  children  of  six  months  or  older.  It  is  under- 
stood that  no  physician  will  forget  the  danger  of  giving  repeated  do?es  of 
paregoric  or  permitting  the  same  to  be  administered  by  incompetent  people 
not  aware  of  the  dangers  of  the  drug  habit.  The  author  has  not  only  seen 
distinct  opium  poisoning  follow  the  use  of  paregoric,  but  has  also  had  occa- 
sion to  see  the  distinct  opium  habit  in  very  young  children.  This  was 
reported  by  me  in  a  paper  read  before  the  New  York  County  Medical 
Society,  January  22,  1894,  which  was  published  in  extenso  in  the  Med- 
ical Record  of  February  17,  1894.  For  an  infant  during  the  first  few 
months,  it  is  hardly  safe  to  give  more  than  5  drops  of  paregoric,  repeated 
in  an  hour  if  there  is  no  relief.  Another  drug  that  has  served  the  author 
very  well  is  Hoffmann's  anodyne  in  doses  of  from  1  to  5  drops,  repeated 
in  an  hour  if  necessary.  For  an  infant  up  to  two  months  1  drop  per  dose; 
from  two  to  four  months,  2  drops  per  dose;  four  to  six  months,  3  drops; 


ACUTE  INTESTINAL  INDIGESTION.  299 

six  to  nine  months  and  until  1  year  of  age,  4  drops;  children  from  1  to 
2  years,  5  drops.  This  is  to  be  given  in  a  teaspoonful  of  sterilized  water. 
Another  valuable  drug,  and  one  that  is  to  be  given  cautiously,  and  in  the 
same  doses  as  Hoffmann's  anodyne,  is  spirits  of  chloroform;  never  should 
more  than  from  1  to  4  drops  be  given  to  a  child  up  to  1  year  of  age,  and 
younger  children  less  in  proportion.  I  cannot  favor  the  administration  of 
nauseating  or  foul-smelling  drugs,  such  as  asafoetida.  We  must  try  to 
cater  to  an  infant's  taste,  especially  so  when  in  pain. 

An  excellent  preparation  to  relieve  colic  is  calcined  magnesia,  or  milk 
of  magnesia,  made  by  Phillips.^  Hare's  "System  of  Medicine"  contains 
an  article  by  Stewart  advocating  its  use.  It  has  served  the  writer  very  well 
especially  in  young  infants,  where  acidity  was  prevalent.  A  half-teaspoon- 
ful  several  times  a  day  was  enough  in  some  cases,  while  others  required 
several  teaspoonfuls  during  the  day.  It  is  valuable  where  constipation 
exists,  and  can  be  added  to  the  bottle  of  food. 

Borborygmus  (Rumbling  Noises). — Children  frequently  have  rumb- 
ling noises  which  are  troublesome.  A  girl  recently  under  treatment  of  the 
writer  had  this  trouble  for  several  years.  The  noises  were  so  loud  that  they 
could  be  heard  in  the  adjoining  room.  They  were  aggravated  by  deep 
inspiration.  Frequently  eructations  of  gas  would  afford  temporary  relief. 
This  condition  is  met  with  in  ectasia  or  in  ptosis  of  the  stomach.  In  the 
case  of  gastroptosis  above  mentioned,  a  tight-fitting  abdominal  bandage 
afforded  relief.  Anti-f ermentatives :  Milk  of  magnesia  in  teaspoonful 
doses  is  beneficial;  powdered  charcoal  in  2  to  5-grain  doses  is  also  useful 
when  taken  shortly  before  meals. 

Acute  Intestinal  Indigestion. 

This  disturbance  originates  in  the  duodenum.  As  a  rule  that  which 
the  laity  describes  as  a  'Tsilious  attack"  is  an  acute  or  chronic  condition 
which  originates  from  food  which  has  not  been  properly  digested. 

Symptoms. — This  condition  is  very  rare  in  young  infants,  but  is  fre- 
quently met  with  in  later  childhood.  Headache  is  a  prominent  symptom, 
associated  with  pain  in  the  abdomen  and  usually  sour  eructations.  The 
breath  is  foul,  the  tongue  is  coated.  Sometimes  undigested  particles  of  food 
will  be  seen  in  the  stools  (lientery).  The  temperature  ranges  between  100** 
and  101°  F.,  rarely  higher.    Either  diarrhoea  or  constipation  may  be  pres- 

^  Philips' s  Milk  of  Magnesia — Bydrated  Oxide  of  Magnesium  (MgH,0,).— A 
teaspoonful  of  Philips's  Milk  of  Magnesia  is  equivalent  in  acid  neutralizing  power 
to  4  ounces  of  lime  water,  or  10  grains  of  sodium  bicarbonate.  It  will  neutralize 
nearly  twice  its  volume  of  lemon  juice.  Each  fluidounce  represents  24  grains  of 
magnesium  hydrate.  Dose:  From  a  teaspoonful  to  a  tablespoonful,  according  to 
age — increased  or  diminished  at  discretion.  Dilute  with  equal  quantity  or  more  of 
water. 


300  DISEASES  OF  THE  INTESTINES. 

eiit.  If  very  little  bile  is  passed  the  stools  may  be  clay-colored.  Rarely 
jaundice  is  present. 

The  prognosis  is  always  good. 

Treatment. — IJeinove  the  cause  if  jjossiblc.  It  is  necessary  to  study  the 
diet  of  tlie  child  and  exclude  undigestiblc  food  which  might  cause  these 
attacks.  During  an  acute  attack  5  drops  of  peppermint  in  a  tablespoonful 
of  hot  water,  or  3  drops  of  Hoffmann's  anodyne  may  be  given  to  relieve 
colicky  pains. 

In  an  article  in  Pediatrics  on  "Gastro-intcstinal  Indigestion  in  Chil- 
dren," Dr.  S.  Henry  Dessau,  of  Xew  York,  says  that  when  spigelia  is  added 
in  moderate  doses  to  the  tonic-laxative  as  in  the  formula  given  below,  it 
appears  to  exercise  a  most  Ijeneficial  influence  in  arresting  the  immoderate 
secretion  of  mucus,  diminishing  flatulence,  relieving  the  sighing  respira- 
tion, and  removing  the  many  nervous  phenomena. 

The  formula  he  employs,  which  may  be  called  a  working  basis,  is  com- 
posed of: — 

IJ  Ext.  spigolia,  fld 2  fluidraclims 

Ext.  .senna,  fld 2  fluidrachms 

Ext.  cascara,  fld. : 1  fluidrachm 

Tr.  mix  vomica 1  fluidrachm 

Tr.  cinchona  comp 4  fluidrachms 

Syr.  sarsaparilla  comp.,  ad 2  fluid  ounces 

M.     Sig.:      1  drachm  ter  in  die. 

The  diet  should  exclude  milk  during  the  acute  attack  for  at  least 
twelve  to  twenty-four  hours,  and  thin  soups  or  broths  and  weak  tea  can. 
be  given  instead. 

Chronic  Intestinal  Indigestion  (Duodenal  Catarrh: 
Mucus  Disease). 

This  condition  is  always  associated  with  a  chronic  derangement  of  the 
stomach.  It  is  usually  a  functional  disturbance  and  is  one  of  the  most 
difficult  conditions  to  treat  in  children. 

Etiology. — This  is  usually  obscure,  although  it  follows  exhaustive  dis- 
eases such  as  typhoid,  diphtheria,  or  other  infectious  diseases.  The  most 
frequent  cause  is  improper  food,  unsuited  for  the  age  and  development  of 
the  child. 

Symptoms.  —  As  a  rule  gastro-enteritis  precedes  this  condition  for 
months,  in  each  and  every  case.  The  stool  shows  a  tendency  to  looseness 
and  mucus  is  found  covering  the  faeces.  The  mucus  is  seen  in  shreds  and 
masses  at  times  covering  the  fjrcal  matter.  Such  children  are  usually 
liackward  in  develojjnieut.  They  are  very  irritable,  tire  easily,  and  loue 
in  weight. 


CHRONIC  INTESTINAL  INDIGESTION.  301 

As  a  rule  the  abdomen  is  distended.  There  is  no  fever.  The  appetite 
varies  and  is  poor.  The  liver  docs  not  functionate  proper]}',  and  in  some 
cases  very  little  bile  is  secreted,  giving  ^ise  to  clay-colored  stools.  The  skin 
is  dry. 

Diagnosis. — The  only  condition  which  might  resemble  chronic  intes- 
tinal indigestion  is  general  tuberculosis.  The  absence  of  cough,  the  ab- 
sence of  fever,  and  the  absence  of  physical  signs  in  the  lungs  should  help 
to  exclude  tuberculosis.  The  diagnosis  will  be  more  readily  made  when 
previous  gastric  or  gastro-intestinal  derangements  are  taken  into  account. 

Prognosis. — This  is  usually  good,  even  though  these  attacks  may  ex- 
tend over  years.  If,  however,  rapid  emaciation  and  general  weakening  of 
the  heart  exists,  the  prognosis  becomes  grave. 

Treatment. — Dietetic  Treatment:  This  is  the  most  important  part 
of  the  treatment  and  requires  very  careful  consideration.  Excessive  fats 
and  sugars  should  be  avoided.  Light  meals  rather  than  heavy  should 
be  ordered.  Give  predigested  food  if  required.  Whey,  skimmed  milk, 
zoolak,  thin  cocoa,  chicken  broth,  beef  broth,  clam  broth,  soft-boiled  egg, 
fish,  oysters,  raw  scraped  steak,  apple  sauce,  baked  apple,  to  be  varied  with 
other  well  stewed  fruit,  should  be  given.  Avoid  all  fresh  bread,  liusk 
(zwieback)  may  be  given.  Give  all  green  vegetables  in  season.  Avoid  all 
heavy  cakes,  pies,  and  puddings.  If  this  light  diet  is  continued  for  several 
months  great  improvement  will  be  noted.  The  ultimate  care  will  dej^end 
on  restricting  the  diet  to  nutritious  and  very  easily  digested  food. 

Medicinal  Treatment. — Give  nux  vomica,  1  to  3  drops,  three  times  a 
day.  before  meals.     Or: — 

IJ  Acid  hychoc-hlor.  dilut 1  ouiue 

Five  minims  three  times  a  day,  after  meals. 

Pay  careful  attention  to  the  bowels;  give  a  laxative  if  necessary.  If 
severe  anaemia  exists  then  give: — 

R  Tr.  ferri  aeet.  a^li 1  ounce 

Ten  drops,  tliree  times  a  day.     One  liour  after  meals. 

IMiis  has  been  found  to  be  the  best  form  of  iron  in  the  management  of 
this  condition. 

A  girl,  8  years  old,  was  breast-fed  in  infancy  and  appeared  apparently 
healthy.  Her  dentition,  walking,  and  talking  normally  developed  about  the  end 
of  the  first  year.  During  the  second  year  she  suffered  with  measles.  When  4  years 
old  she  had  an  attack  of  acute  milk  ])oisoning,  resulting  in  gastroenteritis.  From 
lliis  time  on  she  has  not  been  in  good  health.  She  complained  of  headaches,  naur.ea, 
and  anorexia.  She  has  a  foul  breath,  and  is  very  auiemic.  She  does  not  seem  to 
ilirive.  The  slightest  imprudence  in  eating  causes  gastric  symptoms.  Her  abdoi.ien 
is  huge  and  gas  is  frctiuently  e\pelie<l  per  rectum.  She  is  always  languid.  The 
temperature   is    normal,    tiie    pulse-rate    feelile,    it   usijsj^y   ranges   between   90   and 


302  DISEASES  OF  THE  INTESTINES. 

100.  She  does  not  sleep  well,  talks  in  her  sleep  and  tosses  about.  Under  a  rigid 
diet,  excluding  pure  milk,  and  giving  diluted  milk,  whey,  thin  soups,  soft  boiled  eggs, 
and  fruit,  improvement  was  noted.  The  interval  of  feeding  was  restricted  to  live 
hours,  so  that  the  child  was  fed  three  times  a  day.  A  daily  movement  of  the  bowels 
was  insisted  upon.  One  half-teaspoonful  of  phosphate  of  soda  in  a  teacup  of  warm 
water  was  given  when  the  child  was  constipated.  Five  drops  of  acid  hydrochloric 
dilute  was  given  three  times  a  day.  The  case  improved  and  the  child  is  in  a  good 
condition  to-day. 

Acute  Milk  Infection  (Choleriform  Diarrhoea: 
Cholera  Infantum).^ 

In  bottle-fed  children,  especially  among  the  poorer  classes,  acute  milk 
poisoning  is  frequently  seen  during  the  summer  months.  This  is  due 
mainly  to  the  chemical  or  toxic  product  developed  in  the  milk.  The  heat 
of  the  summer  rapidly  decomposes  milk,  and  large  quantities  of  bacteria 
multiply  and  generate  their  toxic  products.  When  such  milk  is  fed  to 
infants  they  show  the  effect  of  the  toxin  very  rapidly.  Park  found  that 
when  milk  was  first  received  from  the  farms  it  contained  from  10,000  to 
20,000  bacteria  in  each  cubic  centimeter.  On  the  second  day  the  bacteria 
had  so  increased  that  there  was  between  10,000,000  to  30,000,000  per  cubic 
centimeter. 

Langermann-  found  that  a  sterilized  milk  mixture  which  contained 
roughly  from  30  to  40  micro-organisms  when  taken  by  the  infant,  con- 
tained from  4000  to  6000  one  and  one-half  hours  later  when  taken  from 
the  infant's  stomach. 

In  healthy  infants  nursed  at  the  breast  he  found  tlie  same  number  of 
bacteria  in  the  stomach  contents  as  he  did  in  the  stomach  contents  of  in- 
fants taking  sterilized  milk. 

The  stomach  contents  of  infants  suffering  with  dyspepsia  contained 
many  more  organisms  that  that  of  healthy  children. 

He  found  that  hydrochloric  acid  acts  as  an  auti-fermcntative.  Thus  it 
appears  from  his  experiments  that  numerous  organisms  are  present  and 
fourish  in  the  stomach  of  infants  under  normal  conditions^  being  derived 
from  the  food  and  also  from  the  mouth. 

Summer  diseases,  particularly  entero-colitis  and  cholera  infantum,  will 
appear  just  as  readily  in  l)reast-fed  children  Avho  are  improperly  managed 
as  in  bottle-fed  children.  By  improperly  fed  children  I  mean  too  frec/uent 
feeding  or  the  feeding  of  breast-milk  which  is  unsuited  for  the  infant, 
because  of  excessive  fats  or  an  excess  of  proteids.  This  has  already  been 
d&scribed  in  detail  in  the  chapters  on  "Breast  and  Bottle  Feeding." 


'  The   bacteriologj'   is   described   in   the   following  chapter   on    "Subacute   Milk 
Infection." 

^  Jahrbuch  fiir  Kinderheilkunde,  Band  xxxv,  Heft  1  and  2,  p.  88. 


ACUTE  MILK  INFECTION.  303 

Pathology. — There  is  extreme  emaciation  of  the  entire  body  affecting 
muscles  and  fat.  The  fontanel  is  depressed.  The  eyes  are  sunken.  The 
elasticity  of  the  skin  is  gradually  lost,  the  skin  hangs  in  loose  folds.  The 
body  resembles  an  advanced  form  of  tuberculosis.  Minute  hgemorrhages 
are  found  associated  with  intense  congestion  in  the  stomach  and  intestines. 
The  evidence  of  catarrh  is  everywhere  seen.  There  is  an  excessive  secretion 
of  mucus  in  the  larger  intestine;  in  the  colon  ulcers  will  be  found. 

Ashby  and  Wright  describe  a  general  distention  of  the  net-work  of  the 
capillaries  situated  in  the  mucous  membrane  of  the  intestine.  The  same 
condition  is  found  in  the  submucosa,  in  the  villi,  and  between  the  tubules 
and  crypts  of  Lieberkuhn.     "The  central  portions  of  the  solitary  glands 


Fig.  84. — A  Case  of  Acute  Milk  Poisoning  Having  Vomiting,  Diarrhoea, 
Mucous  and  Bloody  Stools,  General  Emaciation,  Acute  Cholera  Infantum  and 
Dysentery.     (Original.) 

are  softened,  or  the  softened  portions  having  been  discharged,  the  remains 
of  the  glands  appear  as  sharply  cut  ulcers,  although  the  sinuses  of  the  brain 
are  found  distended  with  blood.  Occasionally  cerebral  anaemia  may  exist." 
j\Ieningitis  is  rare. 

Causes. — Two  varieties  of  micro-organisms  are  constantly  present  in 
the  intestinal  tract  of  healthy  children.  They  are  described  in  detail  in 
the  article  on  "Bacteria  of  the  Intestine"  and  also  in  my  book  on  "Infant 
Feeding  in  Health  and  Disease,"  page  39,  Third  Edition.  We  rarely  see 
this  condition  in  breast-fed  children,  unless  there  is  present  a  subnormal 
condition  due  to  atmospheric  conditions.  Overfeeding  and  irregular  feed- 
ing also  invite  this  condition. 

See  article  published  by  me  in  the  Medical  Record,  July  13,  1895,  entitled 
"The  Treatment  of  Sunmier  Complaint,  or  Gastro-enteritis  Catarrhalis  Acuta, 
Including  Cholera  Infantum  in  Children." 


304 


DISEASES  OF  THE  INTESTINES. 


The  etiological  factors  can  be  briefly  outlined  as  follows: — ■ 

1.  Food,  improper  quantity  and  quality  of  the  same,  be  it  breast-milk 
or  hand-feeding.  It  is  a  well-known  fact,  cited  by  Jacobi  among  others, 
that  breast-milk  can  also  cause  this  disease. 

2.  The  most  frequent  cause  is  certainly  improper  bottle-feeding, 
wherein  food  unsuited  to  tlie  infant's  digestive  abilities  is  continued,  in 
spite  of  Nature's  efforts  to  warn  us,  as  frequently  manifested  by  either 
vomiting  or  diarrluea.  or  both. 

3.  Milk  from  mothers  sufl'ering  with  tuberculosis  or  syphilis.  Preg- 
nant women,  menstruating  and  all  ana?mic  Avomen,  secrete  such  poor  milk 
that  gastro-entorie  derangements  are  exceedingly  common. 

4.  The  influence  of  tlie  weather  on  digestion,  especially  the  extreme 
heat  of  summer. 

5.  Improper  disinfection  of  the  nipples  after  feeding,  and  consequent 
decomposition  and  formation  of  micro-organisms,  causing  infection;  all 
unsanitary  conditions  deleterious  to  the  henlthy  child. 

An  important  point  to  remember  is  that  very  many  diseases  have 
symptoms  resembling  cholera  infantum  and  must  be  carefully  differen- 
tiated; for  examjjle,  typhoid  fever  occurring  in  midsummer  may  simulate 
this  disease  and  give  rise  to  symptoms  wh.ich  greatly  resemble  cholera  in- 
fantum. We  occasionally  see  children  having  diarrlKca,  vomiting,  and 
fever  in  whom  on  palpation  a  tenderness  in  the  ileo-citcal  region  can  be 
palpated.  Such  cases  may  have  appendicitis  and  still  show  all  the  symp- 
toms of  cholera  infantum.  ^ 

From  reJiahh  statistics  in  Norway  the  mortality  ranges  from  8.5  to 
10. .5  (breast-feeding  only),  while  in  Bavaria  the  mortality  is  about  30  per 
cent,  (mostly  bottle-feeding),  chihlren  being  brought  up  chiefly  on 
farinaceous  foods.  Out  of  400  deaths  of  children  from  summer  diarrhoea. 
Minaret,  in  Bavaria,  observed  9G  per  cent,  were  artificially  fed. 


Table  No.  54. — Population,  Deaths  and  Dcath-RnUs  of  Children  under  Five  Years  of  A(/e, 
During  June,  July  and  August,  from  1891  to  1903  in  {old)  New  York  City. 


Year. 

Population. 

Dcatlis. 

Death-Rate. 

1891 

188.703 

5.945 

120.0 

1K93 

194,21 1 

0,012 

13G.1 

LSI); 

199  SSG 

5,892 

117.9 

18'.)4 

20.-),  70:5 

5.78S 

112.5 

]8tr) 

212,!)s:5 

0.183 

llG.l 

1896 

218,4-J4 

5,071 

103.8 

1897 

222  387 

5,041 

90.7 

1898 

?2fl,51.j 

5,047 

89.1 

1899 

2:!0.842 

4,089 

81.3 

1900 

2;!r),3sr, 

4.502 

77.5 

1901 

240. 1 OG 

4,042 

77.3 

1902 

245.201 

4,387 

71.0 

190.3 

2-)0,518 

4.037 

64.5 

ACUTE  ^HLK  INFECTION. 


805 


Table  No.  55.  — Popvlation,  Deaths  and  Death-Bates  of  Children  under  Five  Years  of  Age, 
from  1891  to  1903  in  {old)  New  York  City. 


Year. 

Population. 

Deaths. 

Death-Kate. 

1891 

'  188,703 

18.224 

96.6 

1893 

194,214 

18,(384 

96.3 

1893 

199.886 

17,865 

89.4 

1894 

205,733 

17,558 

85.3 

1895 

212,983 

18,231 

85.6 

1896 

218,444 

10,807 

70.9 

1897 

223,387 

15,o95 

69.3 

1898 

226,515 

15,591 

68.8 

1899 

230,843 

14,391 

63.3 

1900 

235,386 

15,048 

66.5 

1901 

240,166 

14,809 

61.6 

1903 

245,301 

15.019 

61.3 

1903 

250,518 

13,741 

54.8 

The  above  populations  previous  to  1896  represent  estimates  based  on 
the  proportion  of  children  under  5  to  total  population,  as  existed  at  the 
census  of  1895,  to  wit:  11.3?  per  cent.;  and  from  189(5  on,  to  the  pro- 
jjortion  as  existed  at  the  census  of  1900,  to  wit:    11.46  per  cent. 

The  author  desires  to  thankfully  acknowledge  the  kindness  of  Dr. 
William  H.  Guilfo}-,  of  New  York  Health  Department,  for  furnishing  the 
above  statistics. 

Harry  G.,  ten  months  oldj  bottle-fed,  wa.«  brought  to  me  with  a  history  of 
vomiting,  high  fever,  and  diarrhoea.  The  temperature  was  104°  F.  The  stool  was 
green  and  contained  mucus  and  curds,  and  had  a  very  foetid  odor.  The  stools  were 
a.s  frequent  as  twenty  in  twenty-four  hours.  There  was  a  great  deal  of  flatulence, 
tlie  abdomen  was  distended,  and  there  was  constant  tenesmus.  The  mouth  was 
dr\',  the  tongue  had  a  whitish  fur  coating,  and  in  the  mouth  small  patches  of 
stomatitis  could  be  seen.  The  tongue  protruded  constantly  and  when  liquids  were 
given  they  were  taken  ravenously.  The  mother  stated  that  ordinary  grocer's  milk 
)iad  been  used,  and  that  she  believed  the  milk  had  turned  sour  "after  a  thunder- 
storm." The  diagnosis  of  acute  milk  infection  was  made.  The  stomach  Avas  washel 
b}'  the  use  of  1  quart  of  saline  solution.  Two  drachms  of  castor  oil  was  ordered, 
and  one  hoiu'  later  the  rectum  and  colon  were  flushed  with  1  quart  of  chamomile  tea. 
All  milk  was  stopped.  No  food  was  given  for  six  hours.  A  bland  diet  of  sweetened 
rice  water  and  whey  was  then  given  in  quantities  of  4  ounces  every  two  hours.  As 
a  stimulant,  15  drops  of  whisky  was  given  with  Vioo  grain  of  strychnine  every  three 
liours.  The  child  improved,  and  throe  days  later  1  ounce  of  milk,  with  7  ounces  of 
rice  water,  was  given  every  three  hours.  The  milk  was  gradually  increased  every 
other  day,  and  the  rice  water  decreased.     The  child  recovered. 

Symptoms. — The  two  cardinal  symptoms  are  (a)  vomiting,  (h)  diar- 
rluea.  In  some  instances  the  first  evidence  of  tbis  infection  will  be  fever. 
The  temperature  may  be  as  high  as  103°  to  10.")°  F.  There  will  be  intense 
lliirst.  There  is  no  appetite.  The  infant  will  refuse  its  bottle,  and  if 
forced  to  take  it  will  immediately  throw  it  off.     Bi!e,  mucus,  and  sour 

20 


306  DISEASES  OF  THE  INTESTINES. 

smelling  curd  form  the  bulk  of  the  vomit.  The  abdomen  is  usually  dis- 
tended. There  is  a  great  deal  of  flatulence.  The  stool  is  watery  and  green- 
ish in  color,  with  a  very  foul  odor.  When  the  diarrhoea  continues  for  sev- 
eral days,  the  temperature  may  become  subnormal  and  the  infant's  fore- 
head may  be  covered  with  a  cold,  clammy  perspiration.  The  extremities 
are  usually  cold.  The  child  will  sink  very  rapidly,  owing  to  the  amount 
of  exhaustion.  The  body  is  constantly  drained  by  the  diarrhoea.  Unless 
the  clinical  picture  is  recognized  and  proper  treatment  instituted,  the 
infant  may  sink  into  a  coma  and  have  convulsions,  followed  by  death. 

The  following  case  illustrates  acute  milk  poisoning  in  an  infant  less  than  1 
year  old.  The  infant  was  bottle-fed  and  received  the  food  daily,  modified,  from  a 
milk  laboratory.  This  food  seemed  to  agiee  until  the  time  of  the  present  illness. 
The  child  was  under  the  treatment  of  Dr.  John  Logan  and  Dr.  J.  Martinson,  both 
of  New  York.  The  case  was  seen  by  me  in  consultation  after  several  days'  illness. 
The  infant  was  vomiting  and  had  gicenish  mucus  stools.  There  was  severe 
tenesmus.  The  infant  showed  severe  prostration  and  was  apparently  comatose. 
The  fontanel  was  sunken.  The  pulse  was  very  feeble.  The  circulation  was  poor  and 
the  extremities  cold.  As  no  food  was  retained,  in  addition  to  the  amount  of  toxin 
in  the  circulationj  the  heart's  action  became  weaker  and  weaker.  It  was  very 
difficult  to  rouse  this  child.  In  spite  of  high  saline  colon  injections,  the  child  died 
of  exhaustion  associated  with  general  toxaemia. 

Diagnosis. — The  diagnosis  of  this  condition  is  extremely  easy.  It  is 
usually  aided  by  the  clinical  history.  The  disease  usually  occurs  in  sum- 
mer, although  milk  poisoning  can  take  place  during  any  time  of  the  year. 

Differential  Diagnosis. — Sunstroke  may  sometimes  be  confounded  with 
cholera  infantum,  but  the  continued  diarrhoea  in  cholera  infantuin,  and 
its  history,  should  aid  in  eliminating  this  condition  as  a  factor.  Asiatic 
cholera  shows  symptoms  similar  to  cholera  infantum.  The  presence  of  the 
comma  bacillus  in  the  stools  will  easily  establish  the  presence  of  Asiatic 
cholera. 

The  prognosis  depends  on  the  infant,  its  surroundings,  and  the  amount 
of  infection,  and  the  length  of  illness.  Aw  infant  having  good  vitality  and 
Ijeing  given  a  careful  diet  and  stimulation  with  ])r()per  hygenic  treatment, 
certainly  has  more  chance  than  one  left  in  tlie  city  amid  poor  surround- 
ings with  faulty  hygiene. 

Treatment. — //'  ihe  infant  is  hreast-fed  discontinue  the  breast  at  least 
twenty-four  hours.  During  this  time  rice  water,  f)arley  water,  albumin 
water,  or  very  weak  tea  may  be  given.  Diluted  coffee  is  frequently  ordered 
by  me  when  evidence  of  heart  weakness  exists.  If  the  acute  symptoms  of 
vomiting  and  diarrluca  have  been  stopped  Ijy  appropriate  treatment,  then 
the  breast  may  be  permitted  once  every  six  or  eight  hours,  the  alternate 
feeding  to  consist  of  rice  or  l:)arley  water,  as  previously  described.  In  other 
words,  we  must  return  gradually  to  milk  feeding.    If  acute  symptoms  return 


ACUTE  jNHlk  infection.  307 

wlien  the  fereast-milk  is  given,  then  it  is  a  question  as  to  whether  or  no  the 
breast  should  be  entirel}^  withheld.  Whey  is  a  useful  substitute  when  milk 
is  not  well  borne. 

Bottle-fed  Infants. — Stop  all  cows'  milk. 

A  good  plan  is  to  feed  with  intervals  of  three  and  four  hours  between 
each  meal,  and  if  the  usual  amount  of  feeding  was  six  or  eight  ounces,  then 
it  is  a  good  plan  to  give  but  four  or  six  ounces,  of  either  rice,  barlej-,  or 
farina  water.  Albumin  water,  made  by  adding  the  white  of  a  raw  egg  to  a 
wineglassful  of  sterilized  water  and  a  pinch  of  salt,  is  very  good  to  allay 
thirst,  besides  adding  to  the  nutrition  of  the  child.  Ice-cold  tea  (the  ordi- 
nary black  and  green  tea  mixed)  can  be  given  ad  libitum. 

Hygienic  Treatment. — Cold  bathing  or  bathing  in  cold  or  lukewarm 
water,  to  which  some  sea  salt  has  been  added,  is  very  advantageous;  the 
child  should  be  put  into  the  largest  and  coolest  room  in  the  house,  the  tem- 
perature to  be  from  68°  to  75°  F.  //  sea  air  is  ohtainahle^  then  it  is 
ivise  to  remove  the  child  to  the  seashore,  or  at  least  to  insist  on  daily  e-vcur- 
slons. 

Cold  applications  to  the  head  and  an  ice-bag  over  the  fontanel,  cold 
towels  changed  every  fifteen  or  thirty  minutes  over  the  abdomen,  will  tone 
np  the  nervous  system  in  addition  to  reducing  the  temperature.  I  am 
a  decided  opponent  to  antipyretic  drugs,  and  never  use  anti pyrin  or  phenace- 
tine,  but  invariably  resort  to  hydropathic  measures  for  the  reduction  of  the 
temperature.  Sponging  of  the  body  with  alcohol  and  water  is  very  grateful 
and  refreshing,  besides  a  good  antipyretic  measure.  If  cyanosis  and  cold 
extremities  exist,  then  it  is  wise  to  resort  to  hot  mustard  baths  to  stimulate 
the  circulation. 


STOHLMANN,  PFARRE  8c.  CO.  N.Y. 

Fig.  85. — Exact  Size  of  Catlieter  Used  for  Irrigating  a  Very  Young  Infant. 

Having  noted  the  various  causes  of  summer  diarrhoea,  chief  among 
wliich  is  impro})er  feeding  and  its  resultant  diarrhoea,  the  first  thing  to  do 
is  to  cleanse  the  stomach  and  bowels.    This  can  be  most  readily  accomplished 

by:- 

stomach  Washing. — To  do  this,  I  take  a  No.  10  soft  flexible  (rubber) 
catheter  (No.  8  for  a  younger  infant),  having  more  than  one  opening,  and 
attach  it  to  either  a  2-quart  glass  irrigator  or  a  2  quart  rubl)er  fountain 
syringe.  It  is  far  better  to  use  rubber  tubing  and  a  glass  funr.cl,  as  we  can 
then  easily  watch  the  liquid  enter,  and  it  is  also  more  practical,  as  it  can  bo 
kept  clean  more  readily.  For  irrigating  the  stomach  I  use  the  following 
solution : — 

B  Table  salt   1  teaspoon  f ul 

Boiled  water 1  fjuart 


308 


DISEASES  OF  THE  INTESTINES. 


The  above  quantity  for  one  washing,  to  be  used  until  the  gastric  con- 
tents flow  away  clear.  To  introduce  the  tube  it  is  pushed  through  the 
mouth,  gently  but  rapidly  against  the  pharyngeal  wall,  into  the  oesophagus, 
until  the  stomach  is  reached.  It  should  not  be  anointed  with  oil,  as  we 
normally  have  so  much  mucus  present  that  we  have  Nature's  own  lubrica- 
tion.    Having   introduced   the   tube,   I   raise   the   irrigator   or   funnel   or 


Fifj.  8G. — Stomach  Washing.     Introduction  of  the  catlicter.     (Original.) 


fountain  syringe,  which  has  been  previously  filled  with  1  quart  of  the  salt 
solution  mentioned  above,  and  hold  the  same  about  one  to  two  feet  over 
the  child's  head — no  higher.  The  temperature  of  the  water  should  be  be- 
tween 100°  and  105°  F.  If  there  is  severe  irritability  of  the  stomach,  or 
a  tendency  to  nausea  and  vomiting,  then  it  is  a  safe  plan  to  attach  the 
catheter  to  a  long  tube,  ending  in  a  funnel,  and  using  but  one-half  to  one 
pint  of  the  salt  solution,  allow  it  to  enter  the  stomach  slowly.  We  can 
eyphon  oS  the  contents  of  the  stomach  by  lowering  the  funnel  below  the 


ACUTE  MILK  INFECTION. 


309 


level  of  the  stomach.  After  emptying  the  same  wc  can  again  fill  the  fun- 
nel, and  allow  the  salt  solution  to  flow  into  the  stomach ;  and  so  this  process 
of  syphoning  can  be  repeated  until  the  gastric  contents  flow  away  fairly 
clean. 

It  is  a  good  plan  not  to  continue  the  washing  of  the  stomach,  unless 
urgent  symptoms  of  gastric  fermentation  or  possibly  vomiting  of  food  call 


Fig.  87. — Stomach  Washing.     Syphoning  oflf  the  gastric  contents.     (Original.) 


for  the  same.    It  is  my  plan  to  wait  at  least  one  or  two  daj's  and  note  the 
efi'ect  of  the  stomach  washing  before  repeating  it. 

Having  cleaned  the  stomach,  it  is  a  good  plan  to  prescribe  rest,  and  to 
insist  on  leaving  the  child  several  hours,  without  giving  food  of  any  kind. 
1  usually  order  a  small  quantity  of  an  alkaline  water,  either  Seltzer  or 
Vichy,  Apollinaris  water,  or  plain  boiled  (sterilized)  water.  A  tablespoon- 
ful  of  lime  water,  several  times  a  day,  independent  of  food,  is  also  advan- 
tai^eous. 


310  DISEASES  OF  THE  INESTINES. 

In  all  forms  of  diarrliooa  milk  must  1)c  discontinued.  The  details  of 
feeding  have  already  l)eon  given. 

"When  we  find  a  decided  ohjection  on  tlie  part  of  the  patients  or  their 
parents  to  the  ahove  method  of.  cleansing  the  stomach,  then  we  must  resort 
to:— 

Drug  Treatment. — For  this  purpose  a  large  dose  of  calomel,  V4  of  a 
grain  for  a- child  1  year  old,  is  given  every  two  or  three  hours,  until  watery 
stools  are  produced,  and  this  is  followed  on  the  succeeding  day  by  two  or 
three  doses  (a  teaspoonful  each)  of  castor-oil.  The  tendency  to  constipation 
following  a  dose  of  castor-oil  makes  it  a  valuable  remedy  in  all  forms  of 
diarrhoea.  Bismuth  is  the  sovereign  remedy;  I  have  used  the  subcar- 
bonate,  subnitrate,  salicylate,  and  betanaphthol  bismuth,  and  find  the  latter 
an  extremely  valuable  preparation.  In  doses  of  2  to  5  grains  every  few 
hours,  mixed  with  a  little  boiled  water,  it  not  only  agrees  very  well  with 
children,  but  seems- to  exert  a  healing  effect  in  that  form  of  bacillary  diar- 
rhoea which  is  met  with  in  the  acute  catarrhal  gastro-enteritis. 

Salol  in  doses  of  1,  2,  and  3  grains,  for  each  year  respectively,  is  an- 
other valuable  remedy;  so  a^so  is  resorcin,  in  doses  of  V4  to  1  grain  for 
a  child  1  year  old,  three  or  four  times  a  day.  It  is  advisable  not  to  add 
sugar  for  sweetening,  but  only  glycerine;  the  latter,  however,  in  very  small 
quantities,  as  it  has  a  tendency  to  loosen  the  bowels. 

Nitrate  of  silver  in  doses  of  V50  grain  for  a  child  1  year  old,  repeated 
every  three  or  four  hours,  is  valuable  in  some  cases. 

Tannalbin  and  tannigen  in  doses  of  from  1  to  10  grains  seem  to  act 
well  in  some  cases,  poorly  in  others,  but  are  well  worth  trying  in  those 
desperate  cases  in  which  we  change  the  drugs,  if  they  are  ineffectual. 

Hypodermic  Medication. — In  forms  of  collapse,  where  constant  diar- 
rhoea has  drained  the  system,  it  is  a  good  plan  when  the  extremities  are  cold 
to  give  hypodermic  injections  of  10  to  20  drops  of  whisky.  Sulphuric  ether 
can  also  be  administered  hypodermically  in  the  same  dose  as  whisky.  An- 
other valuable  stimulant  is  musk;  2  to  3  drops  of  tincture  of  musk  admin- 
istered hypodermically  every  hour  will  frequently  rouse  the  circulation. 

When  this  form  of  treatment  proves  unsuccessful,  and  the  condition  of 
collapse  continues,  then  a  good  plan  is  to  resort  to  hypodermoclysis.  This 
consists  of  introducing  a  long  aspirating  needle  (previously  sterilized  by 
boiling)  into  the  loose  connective  tissue  of  the  abdomen,  and  allowing  sev- 
eral pints  of  the  normal  saline  solution,  containing  about  7  V2  grains  of 
table  salt  to  a  pint  of  water,  temperature  100°  F.,  to  flow  in  subcuta- 
neously.  It  is  remarkable  to  note  how  much  liquid  can  be  introduced  in 
this  manner,  and  some  of  the  most  desperate  cases  of  collapse  will  respond 
very  rapidly.  I  have  seen  children  who  previous  to  this  injection  were 
pulseless  suddenly  brighten  up,  and  within  a  few  minutes  show  a  distinct 
radial  pulse.     Too  much  care  cannot  be  bestowed  on  the  sterilization  of 


ACUTE  RHLK  INFECTION.  311 

every  part  of  the  apparatus,  and  the  absolute  cleanliness  of  the  water  to  be 
used  for  this  purpose. 

Rectal  and  Colon  Flusliing. — It  is  advisable  to  irrigate  the  colon  and 
rectum  by  placing  the  child  on  its  left  side,  introducing  a  flexible  rubber 
tube  anointed  with  carbolized  vaseline.  Havicg  passed  the  external  sphinc- 
ter, I  invariably  allow  the  water  to  flow  inta  the  rectum  in  order  to  balloon 
the  same,  and  then  continue  to  push  the  tube  beyond  the  rectum  into  the 
colon.  A  little  difficulty  is  sometimes  encountered,  owing  to  the  spas- 
modic contraction  of  the  muscles,  but  if  we  wait  a  short  time,  using  a  little 
patience,  the  tube  can  easily  be  pushed  into  the  colon.  The  method  pur- 
sued is  the  same  as  described  previously  in  irrigating  the  stomach,  excepting 
that  we  do  not  seek  to  syphon  off  the  contents  of  the  bowels,  but  rather  allow 
a  pint  or  a  quart  of  the  warm  saline  solution  to  flush  the  bowels,  and  in 
this  manner  wash  away  as  much  of  the  offending  debris  as  exists  within  the 
bowels.  I  have  frequently  used  cold  water,  but  I  find  much  greater  benefit 
from  the  use  of  a  warm  solution  of  the  temperature  of  105°  F. 

Besides  table-salt  solution,  a  1  per  cent,  boracic  acid  solution  can  be 
used,  so  also  can  a  1  to  10,000  solution  of  bichloride  of  mercury.  A  solu- 
tion of  10  grains  of  tannic  acid  to  a  pint  can  also  be  used,  and  a  1  to  1000 
solution  of  nitrate  of  silver  is  indicated  in  other  cases. 

Some  of  our  cases  require  irrigation  once  in  twenty-four  hours  for  one 
week,  and  others  again  are  so  greatly  improved  after  one  rectal  washing  that 
it  is  not  necessary  to  resort  to  it  again. 

Starch  injections,  made  by  adding  2  tablespoonfuls  of  the  ordinary 
starch  to  a  quart  of  warm  water  of  a  temperature  of  105°  F.,  may  be  given. 
They  are  very  advantageous,  as  the  colon  changes  starch  into  dextrin, 
which  is  easily  absorbed.  Thus  not  only  does  the  latter  cleanse,  but  it  is 
also  nutritious.  Large  quantities  of  saline  solution  can  be  introduced 
into  the  circulation  by  means  of  colon  washing,  thus  adding  to  the  volume 
of  the  blood.  I  therefore  lay  great  stress  on  this  form  of  treatment,  as 
one  of  the  most  valuable  for  this  depleting  condition.  Thromboses  can 
frequently  be  avoided  by  these  injections. 

When  severe  tenesmus  exists,  painting  of  the  lower  end  of  the  rectum 
with  a  2  per  cent,  solution  of  cocaine  is  frequently  very  advantageous.  Pro- 
lapse of  the  rectum  and  anus  can  frequently  be  prevented  by  applying  a 
strip  of  zinc  oxide  plaster  from  one  buttock  tightly  to  the  other,  so  that  the 
buttocks  will  support  the  bowel  and  mechanically  prevent  its  protrusion. 

Subacute  Milk  Infection  (Summer  Diarrhcea). 

In  this  condition  we  have  a  gastro-intestinal  disorder  due  to  the  toxins 
generated  from  the  bacteria  in  milk.  This  usually  occurs  during  the  sum- 
mer months  when  there  is  great  humidity  in  the  air.  The  symptoms  are 
not  so  severe  as  those  seen  in  the  acute  form  of  milk  infection.    It  is  usually 


312  DISEASES  OF  THE  INTESTINES. 

met  with  among  the  poorer  classes  who  buy  a  cheap  'milk  which  usually 
contains  millions  of  bacteria.  Victor  Vaughn,  of  Ann  Arbor,  Mich.,  in  a 
letter  to  me,  stated  that  although  it  is  possible  to  destroy  all  bacteria  I)y 
repeated  and  continued  sterilization,  he  found  it  impossible  to  destroy  the 
toxins  generated  in  milk  even  though  the  temperature  was  raised  to  300°  F. 

Cause  of  Infant  Mortality. — The  weeds  eaten  by  cows  in  their  summer 
l^astures  are  responsible  for  many  cases  of  gastro-intestinal  disease.  Many 
of  these  weeds  are  poisonous  and  their  juices  pass  into  the  milk.  In 
support  of  this  theory  Hauser  gives  the  statistics  of  mortality  in  a  number 
of  districts  in  his  experience,  classifying  them  by  the  soil  and  the  weeds 
that  grow  by  preference  on  certain  soils.  His  tables  indicate  a  lower  death- 
rate  on  the  granite  and  sandstone  foundation.  He  contends  that  sys- 
tematic eradication  of  weeds  from  pastures  would  banish  certain  gastro- 
intestinal affections  in  infants. 

Bacteriology. — Bacteriological^  investigation  of  summer  diarrhoea  com- 
menced when  Escherich,  in  1886,  published  his  work  on  the  intestinal 
bacteria  of  infants  and  their  relation  to  the  physiology  of  digestion. 
Ticsage,  Hayem/  and  Baginsky  contributed  further  researches,  but  the  most 
important  and  exhaustive  researches  were  made  by  Booker  from  1886  to 
1897.  As  the  result  of  these  he  called  attention  to  three  principal  forms 
of  summer  diarrhoea,  based  on  a  correspondence  of  their  clinical,  anatom- 
ical, and  bacteriological  features:  (1)  dyspeptic  or  non-inflammatory  diar- 
rhoea, in  which  the  obligatory  milk-fii?ces  bacteria  are  found,  chiefly  the 
bacilhis  coli  communis,  the  bacillus  lactis  aerogenes  appearing  in  smaller 
numbers;  (2)  streptococcus  gastro-enteritis,  in  which  there  is  a  general 
infection  and  ulceration  of  the  intestine,  with  streptococci  as  the  pre- 
dominating forms,  some  bacilli  being  present  as  well;  (3)  baeillary  gastro- 
enteritis characterized  by  a  general  toxic  condition  with  less  intestinal 
inflammation,  and  the  presence  in  the  stool  of  several  varieties  of  bacilli, 
the  proteus  vulgaris  being  the  most  common. 

Escherich  studied  the  streptococcus  cases  more  closely  (1897-1899) 
and  found  the  cocci  numerous  and  in  almost  pure  culture  in  the  stools  in 
acute,  severe  cases,  while  it  was  possible  to  ii^olate  them  from  the  urine 
and  the  blood  during  life  and  from  the  viscera  after  death.  Clinically,  the 
symptoms  vary  much  in  the  mild  and  the  severe  cases;  the  stools  may  be 
watery  and  contain  much  pus  and  blood.  Staphylococci  have  also  been 
found  in  diarrhocal  stools,  but  much  less  frequently  than  streptococci.  Later 
Escherich  described  cases  of  dysentery  due  to  a  virulent  colon  bacillus. 
Valagussa  found  a  bacillus  belonging  to  the  colon  group  and  identical  witli 
that  isolated  by  Celli  and  Fiocca  from  cases  in  Italy  and  Egypt.  In  1898 
Shiga,  in  Japan,  described  the  bacillus  dysenterige,  an  organism  more  nearly 


'  An  editorial  in  Archives  of  Pediatrics,  August,  1901. 


Sl\P>ACUTE  MILK  INFECTION.  3I3 

rolated  to  the  typhoid  than  to  the  colon  group,  and  Flexncr  found  the  same 
liaciHus  in  one  form  of  acute  dysentery  studied  in  Manihi.  Both  Celli  and 
Escherich  tried  to  identify  the  hacillus  they  described  with  that  of  Shiga. 
The  bacilkis  pyocyaneus  has  also  been  foimd  in  the  stools  of  cases  of 
epidemic  infantile  dysentery.  It  is  evident,  then,  that  no  specific  bac- 
terium of  gastro-enteritis  has  been  found;  there  is  one  form  in  which  the 
streptococcus  is  the  predominating  organism,  and  the  bacillus  dysenteria^ 
may  possildy  be  proved  to  be  the  cause  of  epidemic  dysentery  both  in  chil- 
dren and  in  adults. 

Pathology. — Inflammatory  lesions  and  ulcerations  can  be  seen  in  the 
colon.  It  is  rare  to  find  the  duodenum  and  jejunum  involved.  The  micro- 
scopical findings  of  the  stool  show  numerous  bacteria,  epithelial  cells,  de- 
tritus, and  occasionally  l)lood.     Sometimes  particles  of  food  are  also  seen. 

Symptoms. — Vomiting  and  diarrhoea  as  in  the  acute  form  arc  the  main 
symptoms.  IF  an  infant  has  just  recovered  from  an  acute  milk  infection 
and  is  placed  on  milk  feeding  too  soon,  a  relapse  frequently  occurs,  which 
is  a  subacute  infection.  The  stools  are  greenish  and  resemble  those  de- 
scril)ed  in  the  acute  form.  There  is  a  loss  of  appetite,  a  coated  tongue,  and 
the  temperature  ranges  l)etwcen  101°  and  105°  F. ;  at  times  the  tempera- 
ture may  l)e  normal  or  subnormal.  The  infant  docs  not  want  to  l)e  dis- 
lurl)ed,  aiul  is  very  irritable.  The  irritation  and  tenesmus  accompanying 
this  diarrhoea  usually  causes  the  rectum  to  prolapse,  and  from  the  constant 
discharges  of  the  bowel  the  anus  and  buttocks  are  excoriated.  An  cczem- 
atous  eruption  frequently  is  seen  between  the  thighs.  Local  infection  of 
the  skin  and  lymphatics,  by  the  presence  of  the  pyogenic  bacteria,  some- 
times causes  furuncles. 

Diagnosis. — This  is  usually  made  when  the  history  and  symptoms  are 
carefully  noted.  It  is  much  milder  than  cholera  infantum.  The  tempcra- 
tiire  is  lower^  the  vomiting  less,  and  the  prostration  not  so  marked. 

•Joiiali  W'.,  spvcn  nioiiths  old,  twin  baby,  bottle-fed,  had  been  constipated  since 
birth.  There  was  a  slight  cough.  The  child  had  beaded  ribs,  cranio  tabes,  and  bald- 
ness of  the  occiput.  Since  one  month  he  had  vomiting  and  diarrhoea.  This  had 
improved  and  disappeared  entirely.  The  child  was  given  milk,  and  ten  days  after 
the  milk  diet  was  commenced  the  symptoms  of  vomiting  and  diarrhoea  again  appeared, 
Itiit  in  a  milder  form.  Several  furuncles  were  found  on  his  scalp.  Owing  to  the 
intolerance  of  milk,  whey  was  given  in  the  same  qnantity  and  frequency  as  the  milk 
was  formerly  given.  Kicc  water,  barley  water  and  thickened  pea  soup  was  allowed. 
Toast  water  was  given  for  thirst.  Cocoa,  was  also  given  without  milk.  The  cocoiv 
was  made  with  rice  water,  in  the  following  propor(inns:  — 

IJ   Cocoa    1   (hachm 

Rice  water    S  ounces 

Sugar    1   drachm 

Scald  about  five  minutes. 


314  DISEASES  OF  THE   INTESTINES. 

A  large  dose  of  castor-oil  followed  by  a  2-grain  dose  of  tannopine  every  two 
hours  was  givou.  A  high  saline  injection,  1  quart,  temperature  115°  F..  was  ordered 
to  cleanse  the  rectum  and  colon;    also  for  its  stimulating  elTect. 

The  diagnosis  of  subacute  milk  infection,  congenital  syphilis,  and  fiuunoulosi.-; 
was  made.     The  case  recovered. 

Prognosis  and  Complications. — This  depends  on  the  condition  of  the 
C'liild.  It'  there  is  a  complication  such  as  nephritis  present  then  the  prosx- 
nosis  is  worse  than  if  uncomplicated.  If  an  infant  can  ])c  removed  to  the 
seashore  from  unsanitary  surroundings  and  proper  food  given,  the  prog- 
nosis is  good. 

Treatment. — Two  points  to  be  considered  in  this  condition  are:  First, 
stop  all  milk  for  at  least  one  week  and  give  the  stomach  and  bowels  alisolute 
rest.  Second,  cleanse  the  stomach  and  hoirels  of  all  offending  debris  which 
may  have  caused  this  trouble.  Such  cases  should  be  put  on  a  light  nutri- 
tious diet. 

The  golden  rule  is  to  give  the  stomach  and  bowels  absolute  rest  in  hci{]\ 
qualitv  and  (juantity  of  food.  The  feeding  interval  should  be  longer  and 
the  amount  of  food  reduced. 

In  suljstituting  other  forms  of  feeding,  pro  tempore,  we  invariably  do 
so  at  the  expense  of  l)ody  weight.  It  will  always  be  noted  that  children 
deprived  of  milk  will  lose  weight  unless  care  is  taken  to  substitute  a  proper 
nutritious  food.  The  body  will  lose  to  such  an  extent  that  atrophy  may 
frequently  follow. 

FoDinild  far  Wvak  Infants  in  Siihstilntc  Frcdinrj. — WJien  vomiting  and  diar- 
rhoea jiersist  give  either:  — 

Barley  Avater    4  ounces 

Rice  Avater    4  ounces 

Oatmeal  water     4  ounces 

Or:  — 

Whey 4  ounces 

Feed  every  two  or  thre(?  hours.     Add  V2  of  yolk  of  egg  to  each  feeding. 

Sweeten  with  granulated  sugar  half-teaspoonful  to  each  bottle.  If 
■♦.'t'vmentation  exists — colic,  greenish  stools,  and  eructations — use  saccha- 
rine, 1/2  grain,  instead  of  sugar  tor  sweetening. 

The  liquid  culture  of  lactic  acid  bacillus,  or  the  lactic  acid  tablets  have 
served  me  very  well  in  acute  entero-colitis,  and  especially  to  control  fermen- 
tation and  colic  caused  by  intestinal  toxic  bacteria.  The  liquid  culture  in 
drachm  doses,  repeated  every  three  or  four  hours  is  non-toxic.  Lactic  acid 
tablets,  one  or  two,  may  be  given  several  times  a  day  regardless  of  the  age 
of  the  child. 


APPENDICITIS.  315 

Medicinal  Treatment. — A  close  of  castor-oil  should  be  given  at  tlie 
beginning  of  the  treatment^,  first  to  cleanse  the  gastro-intestinal  tract,  and 
secondly,  for  its  constipating  after-effect.  Ehubarb  and  soda  mixture  in 
doses  of  one-half  teaspoonful  are  valuable  after  the  castor-oil  has  been  given. 
The  treatment  described  in  the  chapter  on  "Acute  Milk  Infection'^  should 
be  carried  out  as  well  in  this  condition.  The  successful  outcome  of  the 
case  depends  on  proper  rest,  careful  stimulation,  and  a  thorough  cleansing, 
aided  by  a  decided  change  of  air,  to  the  seashore  or  to  the  mountains.  Milk 
should  not  be  given  until  all  conditions  appear  normal.  Essence  of  caroid 
in  teaspoonful  doses,  every  three  hours,  is  serviceable.  Powdered  caroid 
combined  with  charcoal,  in  doses  of  3  grains  each,  repeated  several  times  a 
day,  is  very  valuable. 

Carbolic  acid  is  extolled  by  some  physicians  with  large  experience  in 
infantile  diseases.  S.  Henry  Dessau  strongly  advises  a  1  per  cent,  solution 
of  carbolic  acid  as  an  intestinal  corrective  when  fermentation  exists.  He 
has  not  seen  any  toxic  symptoms  from  its  use.  I  can  fully  indorse  his 
statement  and  usually  advise  watching  the  urine  during  the  administration 
of  carbolized  water.  A  teaspoonful  of  a  1  per  cent,  solution,  sweetened 
with  saccharine,  can  be  given  three  or  more  times  a  day.  If  no  effect  is 
noticed  in  twenty-four  hours  then  1  ^/^  or  2  teaspoonfuls  can  be  given  at 
each  dose.  I  have  also  used  creosote  water,  1  per  cent,  solution,  in  the  same 
doses  as  carbolized  wattfr  with  excellent  results.^ 

Appexdicitis. 

Appendicitis  is  an  inflammatory  condition  in  and  a])out  the  vermiform 
appendix.  Clinical  experience  has  proven  that  inflammatory  conditions 
in  the  right  iliac  fossa  originate  in  the  vermiform  appendix. 

Eacteriology. — The  result  of  bacteriological  investigations  of  appen- 
dicitis is  far  from  satisfactory.  The  study  of  these  cases  simply  empha- 
sizes the  fact  that  the  presence  of  the  streptococcus  is  usually  attended 
with  symptoms  of  the  severest  type.  There  is  a  great  variability  in  the 
streptococci  found  here  as  well  as  in  other  inflammations.  They  may  cause 
but  slight  disturbance,  but  are  far  more  liable  to  result  in  general  peri- 
tonitis or  septicgemia.  It  must  be  borne  in  mind  that  in  cases  of  perfora- 
tion and  abscess  formation  the  absence  from  cultures  of  pyogenic  cocci  is 
of  negative  value.  The  pure  culture  of  the  bacilhis  coli  communis  has 
frequently  been  found  alone,  and  also  associated  with  the  streptococcus  pyo- 
genes. Klecki-  found  that  pathogenic  bacteria  of  a  most  viru'cnt  type  can 
penetrate  the  peritoneal  cavity.  This  penetration  is  either  during  perfo- 
ration or  through  the  lymph  spaces  of  the  damaged  intestinal  walls. 


^  See   cliapter   on   "Acute   Milk   Poisoning'   for   genoral   treatnient  of   Summer 
Dianlui-a. 

^Annalcs  de  I'lustilute  Pasteur,  vol.  lix,  p.  710. 


316  DISEASES  OF  THE  INTESTINES. 

Pathology. — For  the  purpose  of  pathological  differentiation  it  is  better 
to  divide  tliis  affection  into:  First,  catarrhal;  second,  ulcerative;  third, 
gangrenous. 

Catarrhal  Appendicitis. — In  this  form  the  walls  of  the  appendix  are 
found  thickened  and  h3pera^mic.  The  lumen  of  the  tul^e  is  filled  with 
debris  of  inflammation.  If  this  inflamed  condition  continues  the  canal 
may  become  obliterated.     The  catarrhal  stage  frequently  ends  in  resolution. 

Ulcerative  Appendicitis. — In  this  condition  the  process  involves  the 
muscular  coat  because  the  mucous  and  snbmucous  tissues  have  been  de- 
stroyed.    The  ulcer  frequently  terminates  in  perforation. 

Gangrenous  Appendicitis. — In  this  condition,  also  known  as  intestinal 
appendicitis,  rapid  necrosis  of  all  the  coats  of  the  intestine  takes  place.  If 
a  fascal  concretion  exists  and  tlie  ulcer  perforates,  an  infection  of  the  peri- 
toneal cavity  takes  place  from  the  virulent  bacteria.  Partial  or  entire 
necrosis  sometimes  takes  place,  resulting  in   sloughing  of   the   appendix. 

Suppuration  frequently  follows  the  serous  exudation  and  a  localized 
abscess  is  formed.  The  danger  of  such  an  abscess  consists  in  the  perfora- 
tion taking  place  and  the  escape  of  the  })us  into  the  peritoneal  cavity, 
setting  up  a  diffuse  peritonitis. 

Causes.^ — The  etiological  factor  in  appendicitis  is  hard  to  define.  We 
may  have  anatomical  peculiarities  of  structure.  In  some  instances  con- 
tinued constipation.  In  others  the  opposite  condition;  intestinal  catarrh 
and  diarrhcea  have  been  thought  to  be  the  exciting  causes  of  a  given  case 
of  appendicitis.  Irritation  from  toxic  (fiecal)  accumulations  invite,  rather 
than  cause,  this  disease.  Gouty  families  in  which  gall-stones  or  gravel  in 
the  kidney  have  been  found,  are  predisposed  to  this  afl'ection.  The  name 
of  appendicular  lithiasis  has  been  given  to  this  form  of  appendicitis  by 
Koiix. 

Injuries  to  this  region,  exposure  to  extreme  cold  and  overindulgence 
in  purgatives  have  been  looked  upon  as  causative  factors.  Whether  foreign 
bodies,  such  as  seeds  or  hair  swallowed  by  mouth,  will  lodge  in  the  appendix 
and  cause  this  disease,  is  doubted  by  many. 

Symptoms  and  Diagnosis. — In  general  practice  we  deal  with  two  forms 
of  appendicitis.  The  mild  type  commonly  called  catarrhal,  and  the  severer 
form,  the  so-called  perforative  appendicitis. 

Mild  Form. — In  this  form  the  symptoms  are  so  trivial  that  they  fre- 
quently escape  notice.  Pain,  localized,  or  as  it  frequently  happens  diffused 
over  the  whole  abdomen,  is  complained  of.  It  will,  however,  be  noticed 
that  the  pain  radiates  toward  a  focus  which  is  in  the  right  iliac  fossa.  This 
tenderness  corresponds  to  a  point  near  the  outer  edge  of  the  right  rectus 
abdominus  muscle.  If  a  line  is  drawn  from  the  umbilicus  to  the  anterior 
superior  spine  of  the  right  ileum,  this  point  will  be  in  the  center  and  is 
designated  as  McBurney's  point.    There  is  usually  a  tympanitic  percussion 


APPENDICITIS.  317 

souncl,  and  a  circumscribed  area  of  swelling  can  be  felt.  The  tumor  is 
usually  of  an  oval  shape  and  is  about  two  inches  or  less  in  length. 

In  very  young  children  the  attack  is  ushered  in  with  convulsions, 
whereas  older  children  frequently  have  chills.  Icterus,  with  deap  pigmen- 
tation of  the  skin  and  of  the  conjunctival  mucous  membrane,  may  occur, 
but  rarely.  There  is  frequently  such  distinct  retention  of  urine  and  paia 
in  the  bladder  and  external  genitals,  that  we  may  be  misled  from  the 
actual  seat  of  the  disease.  In  order  to  relieve  the  pain  the  child  will 
usually  lie  on  its  back  with  the  right  leg  drawn  up  to  relax  the  abdominal 
muscles. 

Fever. — The  temperature  rises  very  rapidly.  In  severe  cases  it  is  not 
unusual  to  find  it  has  reached  105°  F.  on  the  first  day.  In  milder  forms 
of  this  disease  the  temperature  will  rise  to  103°  F.,  or  less,  on  the  first  day. 
The  temperature  must  not  be  looked  upon  as  a  guide.  iSTot  infrequently  do 
we  find  fatal  cases  in  which  a  normal  temperature  or  even  a  subnormal  tem- 
perature continued  throughout  the  attack.  Continued  h:gh  fever  means 
suppuration.  A  sudden  drop  to  normal  signifies  either  a  resolution  or 
more  frequently  a  perforation. 

The  Pulse. — The  pulse  should  be  the  guide  in  appendicular  inflam- 
matory conditions.  While  the  same  is  usually  accelerated,  a  sudden  increase 
in  the  pulse-rate  should  be  noted  with  suspicion.  The  toxamic  process  can 
therefore  best  he  studied  by  noting  the  character  and  frequency  of  the  pulse. 

Vomiting  is  an  earh^  symptom  and  one  that  occasions  considerable 
discomfort.  In  mild  forms  of  the  disease  vomiting  gradually  subsides. 
When  peritonitis  complicates,  then  vomiting  usually  recurs. 

The  Bowels. — It  is  difficult  to  say  whether  constipation  or  diarrhea 
accompanies  these  attacks.  I  have  seen  several  cases  in  which  diarrhoea 
continued  throughout  the  whole  attack,  so  that  my  suspicion  concern- 
ing typhoid  continued  until  the  localized  area  of  inflammation  formed. 
Frequently  the  symptoms  of  typhoid  fever  are  so  well  marked  that  it  is 
well  to  note  the  characteristic  Widal  reaction  in  differentiating  appen- 
dicitis. On  the  other  hand  I  have  seen  constipation  continue  until  con- 
valescence was  established. 

The  appetite  is  usually  poor.  The  tongue  coate<l  with  a  whitish  fur. 
Accompanying  the  fever  there  is  usually  thirst.  Pains  in  the  right  thigh  of 
a  neuralgic  character  are  frequently  complained  of.  If  a  child  has  fever 
and  pains  resembling  col'c,  especially  on  the  riglit  side,  suspect  appendicitis. 

Differential  Diagnosis. — The  diagnosis  is  usually  not  very  difficult. 
A  sudden  pain  bK-alizcd  in  the  right  iliac  fossa,  associitcd  with  gastric  or 
intestinal  symptoms  and  fever,  should  render  the  diagnosis  easy.  I  rely 
ui)on  the  examination  of  the  blood  as  an  important  guide  in  determining 
the  presence  of  pus  in  the  system.  See  article  and  illustrations  of  blood, 
showing  the  reaction,  in  tlie  chapter  on  "lilood." 


318  DISEASES  OF  THE  INTESTINEa 

We  must  not  mistake  appendicitis  for  an  abscess  in  the  right  ovary. 
The  same  can  be  differentiated  by  a  careful  vaginal  examination.  In  young 
girls  where  this  is  very  difficult,  an  examination  can  be  made  with  greater 
ease  in  the  rectum.  By  means  of  bimanual  palpation  we  can  usually  differ- 
entiate the  same.  Acute  intestinal  obstruction  occurs  frequently  in  young 
children.  When  the  obstruction  is  due  to  an  intussusception,  bloody  dis- 
charges from  the  bowels  are  generally  present.  In  intussusception  the  tumor 
is  found  either  in  the  median  line  or  in  the  left  side,  whereas  in  appendicitis 
it  occupies  the  right  iliac  fossa.  When  there  is  a  strangulated  gut  due  to  a 
volvulus  the  pain  is  not  localized.  In  this  form  of  obstruction  of  the  bowel 
there  is  usually  stercoraceous  vomiting. 

Hip-joint  disease  and  tuberculosis  might  possibly  be  mistaken  for 
appendicitis.  There  are  a  great  many  cases  in  which  a  diagnosis  will  only 
bo  positive  after  the  abdomen  has  been  opened. 

J.  M.,  17  years  old,  was  refeiTed  to  me  with  the  following  history:  She  was 
wet-niii'sed  in  infancy  and  suffered  with  constipation.  When  4  years  old  had  pneu- 
monia, also  scarlet  fever  and  measles.  When  8  years  old  had  diphtheria,  otitis, 
measles,  chicken-pox  and  mumps. 

For  two  years  she  has  suffered  with  violent  cramps  in  the  stomach,  pain  in  the 
back,  and  pain  mostly  in  the  right  side  in  the  region  of  the  liver.  These  pains  last 
from  three  to  four  days;  they  recur  every  three  or  four  weeks,  and  simulate  cramps 
in  the  stomach.  Vomiting  is  frequently  associated  with  these  attacks.  There  is 
usually  a  temperature  ranging  between  101°  and  103°  F.  Severe  headache  and  con- 
stipation always  accompany  these  attacks.  The  menstrual  function  is  perfectly 
normal  and  independent  of  such,  attacks.  From  the  nature  of  the  attacks  and  the 
location  of  the  pains  an  attending  physician  diagnosed  gall-stones  and  biliary  colic. 
There  seemed  to  be  some  tenderness  in  the  ileocaecal  region.  The  case  was  referred 
by  me  to  Dr.  William  T.  Bull  with  a  diagnosis  of  probable  appendicitis.  The  opera- 
tion was  performed  by  Dr.  Bull  and  a  very  long  curved  appendix  was  found  which 
evidently  accounted  for  the  symptoms.  The  gall-bladder  was  explored  and  found  in 
a  noraial  condition. 

The  diagnosis  of  appendicitis  was  positive.  The  girl  made  a  brilliant  recovery 
and  was  observed  by  me  for  many  months.  All  cramps  and  pains  have  subsided  and 
she  is  entirely  cured. 

This  case  illustrates  the  striking  similarity  of  symptoms  pointing  to 
biliary  colic.  The  rarity  of  biliary  colic  in  children  must  bo  considered 
before  a  positive  diagnosis  is  made. 

Course  and  Prognosis. — -The  prognosis  depends  on  the  time  when  treat- 
ment is  commenced.  A  mild  case  of  appendicitis  iikiij  resemhle  colic  iviih 
a  flight  rise  of  temperature  and  pass  off  unnoticed.  If  these  attacks  recur 
our  suspicion  should  be  aroused  and  the  appendix  removed.  It  is  a  good 
plan  for  the  physician  to  call  the  surgeon  in  consultation  when  symptoms 
point  to  appendicitis.  Very  young  infants  do  not  hear  laparotomy  well, 
owing  to  the  shock  caused  thereby,  but  if  the  surgeon  operates  rapidly, 
shock  is  greatly  lessened.    Cases  of  appendicitis  frequently  assume  a  chronic 


PSEUUO-ArPEXDldTIS.  319 

course.  Attacks  may  recur  at  intervals  of  weeks  or  months.  If  the  diag- 
nosis is  jiositive,  it  is  much  wiser  to  operate  during  the  intervals  of  health 
rather  than  run  the  risk  of  a  fatal  complication  such  as  peritonitis. 

Treatment. — First  and  foremost,  absolute  rest  in  bed.  The  choice 
between  hot-water  bags  and  ice-bags  depends  on  individual  experience. 
In  my  own  practice  I  have  always  favored  hot  fomentations.  The  appli- 
cation of  several  leeches  in  the  early  stage  of  the  disease  will  sometimes 
prove  beneficial.  It  is  of  importance  to  see  that  the  bowels  have  an  evacua- 
tion once  or  twice  in  each  twenty-four  hours.  If  vomiting  persists  cracked 
ice  and  champagne  may  be  given.  The  value  of  opium  is  disputed  by  many. 
It  certainly  relieves  pain,  but  prevents,  peristalsis.  My  choice  has  been 
codeine,  Vjo  grain,  increased  to  i/^  grain,  repeated  every  hour,  depending 
on  the  age  of  the  child,  until  the  pain  was  relieved. 

If  the  symptoms  continue  in  spite  of  the  above  treatment,  it  is  pos- 
sible that  medical  treatment  is  insufficient.  Xo  time  should  be  lost,  but 
prompt  surgical  relief  should  be  given. 

When  Shall  We  Operate? — A  very  important  aid  in  diagnosis  and 
in  deciding  the  proper  time  to  operate  and  one  frequently  overlooked,  is 
the  blo(Jd  exaniinatlou^  in  this  condition. 

In  appendicitis  we  have  a  Icucucytosis,  while  in  uncomplicated  intus- 
susception and  typhoid  fever,  especially  in  the  latter,  leucocytosis  is  absent 
and  leucopenia  present.  It  is  easy  to  see  the  value  of  this  differential 
method. 

Now  as  to  its  value  in  deciding  the  proper  time  to  operate : — 

Leucocytosis  means  pus — abscess. 

Leucocytosis  stationary,  that  abscess  is  walled  off. 

Leucocytosis  increasing,  spreading  abscess. 

Leucocytosis  declining,  favorable  course. 

From  which  we  conclude  that  a  steadily  increasing  leucocytosis  is  a 
l)ad  sign — operate;  while  a  steadily  dccrea-'^inf/  leucocytosis  is  a  good  sign — 
don't  operate. 

If  a  general  peritonitis  is  present  operative  interference  must  not  be 
ilelayed.  It  is  in  this  class  of  cases  that  we  find  a  general  septic  process 
and  in  which,  in  addition  to  the  local  manifestations,  we  have  a  general 
systemic  infection. 

PSEUDO-AI'I'EXDICITIS. 

In  atony  of  the  bowel  we  frequently  have  impacted  f'leces.  In  sucli 
cases  1  have  known  constipation  to  cause  colicky  pains  and  sudden  cramps, 
so  that  the  children  would  cry  out  suddenly.  Iiclief  was  quickly  afforded 
by  a  high  soapsuds  enema  which  brought  away  tlie  offending  masses  of 
hardened   faeces.     Fever  is   frequently  an   accompaniment  of  constipation. 

1  Read  also  |h)1\  nuclear  perooiitagf  in  i-liaptor  on   Blood   Examination. 


320  DISEASES  OF  TIIK  INTESTINES. 

Jt  is  therefore  an  important  niattcf  to  cxchulo  all  other  factors  before 
resorting  to  extreme  measures  and  advising  an  appendectomy.  The  fol- 
lowing two  cases  were  reported  by  me  in  Pediatrics,  Vol.  XIII,  Xo.  1, 
1902  :— 

Case  I. — IMaggie  W.,  10  years  old,  was  perfectly  healtliy  until  the  time  of  her 
])re-^eiit  illness.  She  was  siuklenly  attacked  with  pain,  which  was  localized  in  the  right 
hypochondriac  region;  the  pain  was  very  acute  and  was  increased  on  pressure;  the 
abdomen  was  distended  and  quite  tympanitic  on  percussion;  there  was  a  marked 
dullness  in  the  ileoeaecal  region;  tlu-re  was  an  intense  vomiting,  the  vomit  containing 
particles  of  food  along  with  mucus  and  hile  and  had  a  very  ofTensive  odor.  The 
child  vomited  several  times  in  one  hour  and  seemed  to  vomit  whenever  the  pain  was 
most  acute.  The  mother  stated  that  the  child  had  a  regular  movement  of  the  bowels 
once  in  twenty-four  hours,  that  she  had  had  a  movement  th.at  day  and  that  her 
ap])ctite  had  been  quite  good.  She  was  a  very  strong  and  well-nourished  child  with 
no  evidence  of  organic  disease;  there  was  no  hysterical  element;  the  child  complained 
of  no  other  pain  but  that  directed  to  this  abdominal  condition;  there  Mas  a  history 
of  improper  diet  but  no  history  of  traumatism;  the  heart-sounds  were  noiinal;  no 
murmurs  were  audible,  the  lungs  were  normal  on  percussion  and  auscultation;  the 
liver  did  not  seem  to  be  enlarged;  the  spleen  was  ])alpable  but  not  enlarged;  the 
temperature  was  104°  F.,  taken  in  the  rectum;    pulse,  110;    respiration,  20. 

\Mien  first  seen  an  ice-bag  had  been  applied  over  the  most  tender  spot  in  the 
abdomen.  Codeine  in  '/.rgrain  doses  had  been  administered  and  a  liquid  diet  pre- 
scribed. The  child  was  first  seen  liy  me  abo^'t  twenty  hours  after  the  commencement 
of  her  illness  with  the  above-named  conditions.  As  this  case  had  been  seen  by 
another  colleague  I  was  requested  to  meet  him  in  consiiltation.  The  diagnosis  of 
perityphlltic  abscess  had  been  made  and  an  operation  advised.  The  diagnosis  was 
not  so  positive  owing  to  the  history  of  overeating.  The  child  partook  of  many 
kinds  of  cake  and  pastries  while  celebrating  a  birthday,  and  an  overloaded  stomach 
appeared  most  plausible.  Hence  an  acute  catarrhal  gastritis  was  diagnosed.  The 
pain  and  tenderness  in  the  abdomen  was  ascribed  to  a  colicky  condition,  resulting 
from  fermentative  processes  in  the  stomach  and  extending  into  the  intestine.  The 
indication  was  to  cleanse  the  stomach  and  bowels  as  rapidly  as  possible  and  thus 
remove  the  toxaemic  condition  which  existed.  Meanwhile  an  operation  was  not  con- 
sidered vmtil  after  the  above  measures  were  used. 

The  urine  was  examined  and  showed  a  large  excess  of  phos])hates;  no  albumin, 
no  sugar,  no  casts,  no  diazo-reaction ;  hence  A\e  excluded  tyi)lioid.  There  was  a  very 
strong  indican  reaction  and  this  latter  strengthened  the  diagnosis  of  fermentation 
due  to  intestinal  putrefaction. 

The  Treatment. — I  suggested  the  use  of  a  very  high  enema  witli  a  long  tube 
reaching  into  the  colon;  the  enema  consisting  of  1  pint  of  glycerine  diluted  with  2 
])ints  of  warm  water;  the  temperatuie  of  the  same  was  10'i°  F.  The  enema  was 
very  effectual  and  brought  away  a  large  amount  of  g;is.  The  t;'mi)tn-ature  which, 
as  above  stated,  was  104°  F.,  fell  to  102°  F.  within  one  hour  and  gradually  returned 
to  normal  in  twelve  hours,  although  no  other  antipyretic  measure  was  used.  Small 
doses  of  citrate  of  magnesia  were  ordered,  a  tablespoonful  hourly,  to  quench  thirst 
and  at  the  same  time  to  have  a  slight  laxative  effect.  A  liquid  diet  was  continued, 
iind  thirty-six  hours  after  the  above  remedies  were  ordered  the  child  was  in  a 
normal  condition. 

Case  H. — A  female  child,  about  10  years  old,  was  seen  by  me  tlirough  the 
courtesy  of  Dr.   L.  Harris,  with  severe  abdominal   symptoms.     The   most  prominent 


pseud;)-appp:xdicitis.  32i 

sj-mptom  was  an  intense  pain  localized  in  the  right  hypochondriac  region,  more  espe- 
cially in  the  ileocaecal  region.  There  was  a  marked  distention  of  the  whole  abdomen; 
there  was  constipation  and  vomiting;  the  tt-mperaturc  ranged  between  102°  and 
103°  F. ;  the  pulse,  which  was  110,  rose  to  120.  The  child  complained  of  an  intense 
headache;  in  the  beginning  she  also  had  a  chill.  The  history,  as  given  to  me  by 
Dr.  Harris,  was  that  the  child  had  fallen  from  a  fence  on  which  she  was  standing,  in 
tlie  yard,  a  distiince  of  about  three  feet.  He  believed  that  she  had  injured  herself. 
Tlie  doctor's  diagnosis  was  peritonitis  from  traumatism.  In  this  diagnosis  I  con- 
curred. There  was  no  distinct  localized  area  of  pain,  but  rather  a  diffused  area  of 
pain  extending  over  the  whole  of  the  abdomen,  which  was  intensified  in  the  immediate 
locality  of  the  injury.  There  were  no  chills;  there  were  no  rigors;  the  tempera- 
ture rose  gradually;  there  was  no  evidence  of  suppuration  and  none  suspected. 
The  child  was  placed  on  a  carefully  restricted  liquid  diet,  consisting  of  broth,  soup, 
strained  gi'uel,  milk,  egg  albumin  in  various  forms  and  in  addition  thereto  opium  in 
the  form  of  deodorized  tincture  was  given  to  alleviate  pain.  Attention  was  directed 
to  the  bowel  and  an  enema  was  given  to  flush  the  rectum  and  colon  and  relieve 
accumulated  faeces. 

Another  colleague  saw  the  child  and  diagnosed  appendicitis,  and  suggested 
immediate  operative  treatment.  I  was  again  requested  by  the  attending  physician, 
Dr.  Harris,  to  meet  with  this  other  colleague,  and  as  a  result,  we  decided  not  to 
have  operative  interference  until  we  were  satisfied  that  we  were  dealing  with  a  puru- 
lent case.  Palliative  measures  were  used,  such  as  ice,  locally.  In  addition  thereto 
the  most  absolute  rest  was  enjoined,  and  the  child  made  a  brilliant  recovery  without 
an  operation.  We  were  satisfied  that  we  were  dealing  with  a  traumatic  peritonitis 
in  which  the  local  area  of  pain  was  due  to  the  traumatism. 

A  careful  review  of  the  above  two  cases  will  show  that  when  the  diag- 
nosis of  appendicitis  is  made  l)y  a  process  of  exclusion  then  greater  care 
should  Ije  exercised  before  resorting  to  extreme  measures. 

In  the  first  case  the  high  temperature  and  the  suddenness  of  the 
attack  certainly  showed  marked  symptoms  pointing  toward  appendicitis. 
The  high  temperature  was  due  to  the  toxa^mic  condition  resulting  from 
impacted  fgeces.  The  pain  was  an  enteralgia  due  to  a  distended  gut  filled 
with  gas.  Such  colicky  conditions  are  so  frequent  in  young  infants  that 
we  could  operate  very  frequently  if  the  diagnosis  of  appendicitis  were  made 
every  time  an  infant  screams  with  pain.  The  cases  above  reported  are  very 
interesting  as  showing  tliat  cases  will  frequently  have  symptoms  resembling 
perityphlitis  or  perityphlitic  aljscess,  so  that  a  differential  diagnosis  will  be 
very  hard  to  make.  Xot  infrequently  cases  of  appendicitis  will  be  over- 
looked, and  when  such  is  the  case,  if  tliey  are  of  the  catarrhal  type,  no 
barm  will  ensue  therefrom.  On  the  other  hand,  I  must  not  be  understood 
as  disparaging  tlie  idea  that  no  case  of  appendicitis  requires  an  operation, 
Ijut  my  object  in  calling  attention  to  these  two  cases  is  to  offer  a  plea  that 
before  a  case  of  supposed  appendicitis  is  subjected  to  an  operation,  that  we 
sliould  be  sure  that  all  other  conditions,  such  as  im])acted  fcvces,  as  in  my 
fii-.st  case,  and  other  allied  conditions  have  been  excluded  in  the  diagnosis. 


322  DISEASES  OK  TIIK    I  .\  TKSTIN  KS. 

ArTO-IXTOXR'ATIOX. 

In  very  young  infants  an  to- intoxication  of  the  intestines  is  caused  l)y 
protcid  or  fatty  indigestion  and  rerinentation.  and  is  one  of  the  most  fre- 
quent causes  of  liigh  fever. 

Too  frequent  feeding,  or  the  fi'cding  of  food  containing  a  liigh  fat  or 
excessive  proteid  suitaljle  for  tlie  infant,  provokes  dyspeptic  indigestion. 
From  this  indigestion  we  have  fever  and  tlie  products  of  decomposition 
resulting  in  toxaemia.  If  this  toxsemia  continues  convulsions  frequently 
follow. 

/Another  common  form  of  auto-intoxication  met  with  is  due  to  stagnant 
faices.  An  im])acted  stool,  especially  if  atony  of  the  intestine  exists  will 
frequently  cause  a  rise  of  temperature  and  give  marked  systemic  disturh- 
ances  such  as  loss  of  appetite  and  headache.  The  ahdomen  is  distended, 
notahly  the  transverse  colon.  The  urine  is  high  colored  and  gives  an 
indicau  reaction. 

The  treatment  consists  in  relieving  the  bowels  by  an  injection  of  one 
pint  of  soap  water.  Internally  5  grains  of  compound  jalap  powder  with  2 
grains  of  calomel  should  be  given.  j\Iilk  should  be  stopped.  Whey  or 
thin  broths  should  be  given  for  at  least  twenty-four  hours.  Water  liberally 
is  required. 

Intussusception^. 

The  most  frequent  form  of  obstruction  of  the  bowel  is  that  known  as 
intussusception,  or  invagination  of  the  bowel. 

Intussusception  involves  three  layers  of  the  bowel,  each  layer  consist- 
ing of  all  the  intestinal  coats:  First,  the  outer  layer  is  known  as  the  intus- 
suscipiens,  the  sheath  or  receiving  layer ;  second,  the  internal  is  known 
as  the  entering  layer  which,  together  with  the  third,  the  middle  or  return- 
ing layer,  constitutes  the  invaginated  ])art  known  as  the  intussusceptum. 

The  clinical  records  show  that  alx)ut  one-half  of  all  cases  occur  at  the 
junction  of  the  small  and  large  intestine. 

When  the  ileum  l^'conies  invaginated  in  the  colon,  the  condition 
is  termed  ileo-colic  intussusception. 

In  less  than  one-third  of  all  cases  invagination  takes  j^lace  in  the  small 
intestine.  This  is  known  as  ileal  or  jejunal  intussusception.  When  this 
invagination  takes  place  only  in  the  large  intestine  it  is  called  colic  intus- 
susception. 

This  usually  commences  at  the  ileo-c:i'cal  valve  and  extends  down- 
ward. It  is  felt  as  a  tumor  much  lai'gcr  llian  tlu^  swelling  found  in  ajjpen- 
dicitis. 

Intussusception  vsiialJi/  (■(tusrs  a  rcrcssion  of  llir  ahiJoincn.  from  the 
side  of  the  ccecum,  ivliile  appendicitis,  if  li  docs  (Dn/IJiiinj.  irill  al  least 
prevent  recession  of  the  ahdoiiiimd  walls  ai  Ihis  point. 


I 


INTUSSUSCEPTION.  323 

Symptoms  and  Diagnosis. — Xausea  and  vomiting  are  among  the 
earliest  symptoms.  Later  in  the  disease  the  vomit  becomes  fascal  (so-called 
stercoraceous  vomit)  in  character.  The  child  has  pain;  assumes  the  dorsal 
position  witli  the  thighs  drawn  up  on  the  abdomen.  The  pain  appears  in 
paroxysms  accompanied  with  a  discharge  of  blood  and  nuicus.  Eectal 
tenesmus  also  is  present.  The  temperature  ranges  between  101°  and  103°  F. 
The  pulse  from  120  to  150  per  minute. 

Cases  that  give  a  clear  history  of  intestinal  obstruction  with  no  stool 
passing,  and  vomiting  caused  by  such  obstruction,  offer  a  good  prognosis  if 
operated  early.  Continued  vomiting  of  food  will  cause  exhaustion  and  rob 
the  infant  of  the  vitality  necessary  to  undergo  the  shock  caused  by  the 
operation. 

The  following  case  will  illustrate  intussusception  as  met  with  in  gen- 
eral practice.     The  history  was  as  follows : — 

Infant  B.,  five  months  old,  had  vomited  for  some  time;  was  constipated,  having 
had  no  stool  for  several  days.  The  temperatvu-e  was  about  normal ;  the  abdomen 
was  distended.  Antiperistaltic  movements  of  the  stomach  were  noticed.  The  cliild 
was  breast-fed.  Tlie  breast  was  discontinued  for  a  short  time  and  bark»y  water  sub- 
stituted to  relieve  the  vomiting. 

<^       ^        ^ 


STOilACH.  ^__ ,  ANUS. 


Fig.  88. — Mechanism  of  Intussusception  (Treves).  The  sheath  at  A 
passes  to  B,  tlien  to  C.  The  lower  part  of  the  intestine  is  drawn  over  the 
upper  instead  of  the  upper  crowded  into  the  lower.  For  a  fuller  descriptit)ii 
see  Treves's  "Intestinal  Obstruction,"  London,   1884. 

The  family  was  alarmed  and  sent  for  Dr.  A.  E.  Isaacs,  of  this  city,  througli 
whose  courtesy  I  saw  the  child  several  times  in  consultation. 

The  vomiting  continued  in  spite  of  the  withdrawal  of  the  breast-milk. 
Paroxysms  of  pain  constantly  recurring.  Infant  screaming.  Repeated  enemas 
did  not  result  in  emptying  the  bowels.  Calomel  had  been  given  in  both 
large  and  small  doses  with  no  satisfactory  result.  In  addition  thereto 
cathartics  had  been  given,  and  this  did  not  produce  a  cathartic  effect.  As 
the  vomiting  persisted,  we  believed  that  lavage  would  be  of  some  benefit.  The 
stomacli  was  carefully  washed  with  the  aid  of  a  Nelaton  catheter.  The  cleansing 
solution  was  1  quart  of  normal  salt  solution.  The  gastric  contents  were  syphoned 
off  until  the  return  flow  was  clear.  The  stomach  was  then  given  rest  for  half  a 
dozen  hours  and  tlie  breast-milk  was  again  tried.  The  vomiting  persisted,  at  the 
.same  time  the  distention  in  the  abdomen  continued.  The  diagnosis  intussusception 
was  made  and  an  operation  suggested.  The  family  objected  to  the  operation  and 
]mlliative  measures  were  used.  The  nurse  was  able  to  pass  about  fourteen  inches  of 
catheter  into  the  gut  until  she  reached  the  obstruction.  We  had  ho])ed  that  probably 
a  slough  would  relieve  this  strangulated  gut.  Later  in  the  disease  Dr.  Isaacs  was 
able  to  feel  the  mass  of  gut  in  the  rectum  about  two  and  one-half  inches  from  the 
anus,  and  to  pass  a  catheter  outside  of  the  intussusception,  as  well  as  inside  of  it, 
some  fourteen  inches  without  reaching  the  limit  of  the  invagination.     The  child  was 


324  DISEASES  OF  THE  INTESTINES. 

seen  by  me  at  three  different  times.  The  symptoms  which  were  most  marked  in 
this  case  were: 

1.  Continued  vomiting. 

2.  Faecal  impaction,  the  gut  being  so  obstructed  that  no  fseces  passed  in  more 
than  ten  days,  though  flatus  would  occasionally  pass. 

3.  During  the  first  two  or  three  days  not  only  was  clear  blood  passed  per 
rectum,  but  large  masses  of  jelly-like  mucus  tinged  with  blood  were  frequently 
expelled  from  the  rectum  until  the  end. 

4.  The  distended  belly,  the  abdomen  abnormally  distended,  and  very  tympanitic 
on  percussion. 

5.  The  absence  of  all  inflammatory  symptoms  such  as  rise  of  temperature  until 
two  days  before  the  death  of  the  patient,  when  the  temperature  rose  to  101"  F.  and 
the  pulse  rose  to  160.     (See  Fig.  89.) 

6.  Continued  crj'ing;    the  child  with  rare  exceptions  showed  evidences  of  pain. 
There  was  no  positive  etiological  factor  in  this  case,  as  there  were  two  other 

healthy  children  in  this  family;  the  father  and  mother  were  in  apparent  good 
health.  There  was  no  evidence  of  traumatism  nor  anything  that  could  be  connected 
with  the  cause  of  this  condition.  The  mother  stated  that  for  a  period  of  two  months 
before  the  appearance  of  this  condition  she  had  given  a  patent  cathartic  every  day, 
as  she  thought,  with  advantage.  Whether  or  no  this  drug  had  anything  to  do  with 
tliis  condition  it  is  difficult  to  state.  The  presumption  is,  however,  that  the  con- 
tinued effect  of  giving  cathartics  was  indirectly  the  cause. 

In  the  above  reported  case  an  operation  was  refused  and  the  child 
died.    The  chances  were  in  its  favor: — 

1.  Because  it  was  a  well-developed  and  well-nourished  baby. 

2.  Because  it  was  breast-fed. 

3.  Because  the  diagnosis  was  made  very  early  in  the  disease. 

4.  Because  the  heart's  action  was  very  good,  and  no  chronic  or  infec- 
tious disease  existed. 

In  1870  Pilz^  reported  94  cases  under  1  year — mortality,  84  per  cent. 
From  1870  to  1891  135  cases,  under  1  year,  gave  mortality  of  59  per  cent. 

The  reduction  in  percentage  of  mortality  in  recent  years  is  evidently 
due  to  modern  aseptic  surgery.  Whereas,  formerly  recovery  depended  on 
sloughing,  to-day  laparotomy  is  the  rule. 

Two  interesting  clinical  points  which  I  have  made  use  of,  are  given  by 
Caille:— 

1.  Try  to  reduce  the  obstruction  by  non-operative  means — injections 
of  oil — the  child  in  an  inverted  position  following  the  injection;  gentle 
manipulation  of  the  abdomen. 

2.  In  percussing  the  abdomen  there  will  generally  be  found  at  the 
site  of  the  obstruction  a  very  tympanitic  area  adjoining  a  dull  area.  By 
carefully  noting  this  point  the  surgeon  has  an  important  landmark  for  his 
guidance  in  performing  the  operation. 

Prognosis, — Without  operation  the  prognosis  is  exceedingly  bad.  The 
earlier  the  operation  the  better  the  result.     In  some  cases  Nature  relieves 


'  Jahrbuch  filr  Kinderheilkunde.     Bd.  iii,  p.  6. 


UMBILICAL  HERNIA.  325 

the  invagination  and  a  slongh  will  separate.     This  is,  however,  a  rare  con- 
dition. 

Treatment. — When  the  diagnosis  is  established  no  time  should  be  lost. 
Inflation  of  ike  howcl  with  air  or  hydrogen  gas  through  a  long  rubber  tube 
lias  lieen  recommended.  When  this  is  not  successful  the  child  may  be  in- 
verted and  gentle  manipulation  of  the  abdomen  may  be  attempted. 

Injections  may  be  given  with  or  without  anaesthesia.  The  baby  is 
turned  on  its  belly,  the  hips  are  raised  by  gently  supporting  the  abdomen 
on  a  soft  pillow.  The  mouth  and  nose,  being  the  lowest  part  of  the  body, 
must  be  protected.  The  l)aby  is  then  anesthetized  with  chloroform,  and 
warm  water  is  poured  into  the  rectum  with  but  little  pressure,  from  a 
height  not  exceeding  three  feet.  The  injection  is  frequently  intermitted, 
while  the  anus  is  closed  with  a  cotton  plug  held  by  the  finger.  At  the 
same  time  the  abdomen,  in  the  direction  from  below  upward,  is  gently 
kneaded  and  its  contents  moved  about. 

Unless  this  proves  successful  no  time  should  be  lost  and  an  abdominal 
operation  should  be  performed. 

Although  surgical  interference  offers  the  best  means  of  treatment,  we 
should  note  the  condition  of  the  child  at  the  time  of  operation,  and  con- 
sider the  result  of  shock  and  haemorrhage  in  estimating  the  therapeutic 
result.  Xo  cathartics  should  be  given  after  the  operation,  but  the  bowels 
sliould'be  confined  by  administering  a  small  dose  of  opium.  Stimulation 
will  be  urgently  demanded,  hence  whisky  or  iced  champagne  should 
be  given  ah  libitum.  It  is  well  to  remember  that  very  young  children  do 
not  offer  good  resistance  to  the  shock  of  an  al)dominal  section.  Fully  50 
per  cent,  of  cases  seen  by  me  were  fatal.  The  details  of  an  operation  for 
intussusception  are  those  of  aseptic  surger}^  for  which  my  readers  are 
referred  to  the  special  books  on  surgery.  Dr.  John  F.  Erdman,  of  Xew 
York  City,  has  reported  a  series  of  successful  operations  in  very  young 
children. 

Umbilical  Hernia.* 

This  condition  is  frequently  seen  in  both  male  and  female  children. 
It  is  more  often  seen  in  the  female. 

Causes. — It  is  usually  found  in  children  with  flabby  muscles  such  as 
rachitic  and  atrophied  cases.  Severe  abdominal  strain  during  the  parox- 
ysms of  whooping-cough  or  in  continued  constipation,  frequently  results 
in  umbilical  hernia.  The  tumor  may  be  from  one-half  to  one  inch  wide, 
and  the  same  also  in  length. 

Treatment. — Preventative  Treatment:  After  the  umbilical  cord  has 
separated,  the  usual  flannel  binder  may  be  used  to  lend  support  to  the 
abdomen  for  the  first  two  or  three  months. 


'For  Inguinal  Hernia,  see  cliaptor  on  "Diseases  of  tlic  Genilo-Uiinaiy  Tract." 


526 


DISEASES  OF  THE  INTESTINES. 


Mechanical  Treatment. — A  pad  of  absorbent  cotton  into  which  a  thick 
piece  of  cork  or  a  wooden  button  the  size  of  a  35-cent-piece  is  wrapped, 


Fig.    90. — Umbilical    Hernia.      Tlie    result    of    violent    paroxysms    of 
whooping-cough.      (Original.) 


should  be  snugly  pressed  over  the  protruding  part  and  secured  by  thick 
straps  of  zinc  oxide  j^laster.     This  dressing  should  be  renewed  every  four 

,'  or  five  days.    The  treatment  must  be 
continued  for  several  months. 

A  truss,  consisting  of  a  rubber 
pad  and  a  belt  to  pass  around  the 
body,  should  be  applied,  so  that  it 
cannot  slip  and  has  enough  pressure 
to  keep  the  hernia  in  place. 


Fig.  91. — Umbilical  Hernia  Truss. 


Tapeworm  (Cestodes). 

The  tapeworm  enters  the  body  by  food  containing  the  harvje.  Sev- 
eral varieties  are  met  with.  When  the  worm  is  fully  developed  it  consists 
of  rectangular  segments  or  pieces.  These  segments  are  also  called  pro- 
glottides.    The  head  and  neck  of  the  worm  are  called  scolex. 

The  eggs  (larvae)  of  the  tienia  solium  are  found  in  pork;  taenia 
mediocanellata,  in  beef;  bothriocephalus  latus,  in  fish;  taenia  cucumerina, 
in  dogs  and  cats. 


PLATE  XII 


Cestodos  (Tapo-worms) .  1,  Taenia  saginata.  ^1,  Iload  of  taenia  sagi- 
nata.  2,  Dorsal  view  of  the  head.  3,  Apex  view  of  head,  showing  depres- 
sion in  center.     J/,  Isolated,  elongated  segments.     5,  Bothrioeephalus  latus. 

6,  Ripe  segments  of  taenia  saginata.     li,  showing  location  of  sexual  organs. 

7,  Half-developed   segments   of    tiBnia   saginata.      Illustrations    drawn    from 
specimens.      (Original.) 


TAPEWORM.  327 

Development  of  the  TFor/n. — A  worm  develops  in  about  three  months. 
When  the  terminal  segments  are  mature  they  separate  and  are  discharged 
in  the  stool.  As  each  segment  contains  both  male  and  female  organs,  each 
one  is  capable  of  regencratiug  a  whole  worm.  For  this  very  reason  the 
treatment  of  a  tapeworm  will  never  be  successful  until  the  head  and  every 
segment  has  been  expelled.  Tapeworms  are  estimated  to  live  from  ten  to 
twenty,  and  possibly,  thirty  years. 

The  beef  tapeworm  is  the  most  frequent  found  in  children.  It  has 
four  suckers,  a  square  head,  and  no  hooks.  Eaw  meat  may  contain  the 
C3'sticerci. 

The  pork  tapeworm  is  the  rarest  found  in  children.  The  head  has 
four  suckers,  surrounding  which  there  is  a  circle  of  about  twenty-six  hooks. 
The  length  of  the  worm  varies  from  ten  to  fifty  feet.  Nursing  childreii 
are  exempt  from  tapeworm. 

Symptoms. — In  children  between  2  and  4  years  of  age  sulijective 
symptoms  are  difficult  to  interpret.  In  older  children  we  will  notice 
attacks  simulating  colic  associated  with  fairly  good  movements  of  the 
bowels.  There  is  restlessness  at  night  and  marked  nervous  irritability  by 
day.  The  breath  is  foul  and  the  child  presents  evidences  of  marked 
anwmia.  In  spite  of  an  abnormally  large  appotite  the  body  wastes  and 
the  child  is  believed  to  suffer  with  some  latent  form  of  tuberculosis. 

Diagnosis.- — The  diagnosis  is  positive  only  when  segments  of  the  worm 
are  found.  The  absence  of  cough  or  pulmonary  symptoms  will  usually  aid 
in  excluding  tuberculosis.  At  times  several  weeks  will  pass  before  a  posi- 
tive diagnosis  can  be  made. 

Prognosis. — The  prognosis  is  usually  good.  It  is  simply  necessary  to 
use  radical  treatment  to  dislodge  and  sicken  the  worm  and  then  expel  it. 

Treatment. — The  tsenicide  should  be  given  after  fasting  and  followed 
in  an  hour  by  a  cathartic  to  carry  otf  the  worm.  The  best  taenicides  are 
pomegranate  or  its  alkaloid,  pelletierine ;  filix  mas;  kousso;  pumpkin- 
seed  ;    turpentine,  and  cocoanut. 

E,  Olco  rcsinse  aspidii 1  fiuidiaclim 

Tinet.    quillaiae '/a  fluidrachm 

Tinct.  aiuantii   duleis 1  fluidrachm 

Syr.  ainantii,  q.  s.  ad 7  fluid  ounces 

M.      Sig. :      A  tcaspoonful  for  a  child  5  years  old  (C.  W.  Towiisond). 

I^  Tannate   of  pelletierine Vs  grain 

Sig.:      For  a  child  3  to  5  years  old  (T.  M.  Rolch). 

IJ  Olei    terebinthinse 1  fluidrachm 

Ol'^i  ricini V2  ounce 

M.     Sig. :      Take  it  in  one  dose  (Farqhuarson). 


328  DISEASES  OF  THE  INTESTINES. 

Since  entire  expulsion  of  the  tapeworm  is  effected  with  difficulty, 
preparatory  treatment  for  about  forty-eight  hours  should  be  employed 
before  the  vermifuge  is  administered.  During  this  time  the  patient  should 
take  a  mild  purgative  once  or  twice,  and  such  food  in  moderate  quantity 
should  be  allowed  as  leaves  little  residuum,  as  beef-tea,  etc.,  with  some 
stimulant  if  the  patient  feels  exhausted.  There  are  three  articles  of  food 
which  experience  has  shown  to  be  especially  useful  in  this  preparatory 
treatment,  perhaps  from  a  sickening  effect  which  they  produce  upon 
the  worm,  namely,  salt  herrings,  onions,  and  garlic.  This  may,  therefore, 
be  taken  as  food  in  the  twelve  or  eighteen  hours  preceding  the  employment 
of  the  vermifuge,  which  it  is  ordinarily  most  convenient  to  adndnister  iu 
the  morning.     (J.  Lewis  Smith.) 

ASCARIS    LUMBRICOIDES    (RoUND    Worm). 

This  worm  is  a  reddish  or  yellowish  round  worm,  usually  from  5  to 
10  inches  long.  The  male  worm  is  smaller  than  the  female.  This  worm 
inhabits  the  small  intestines.  It  is  seldom  found  solitar}',  but  usually  4 
to  10  may  be  present.  Some  authors  state  that  as  many  as  200  and  300 
have  been  found  at  one  time.  The  worm  is  usually  found  in  children  be- 
tween the  second  and  tenth  years.  It  is  never  found  in  nurslings.  These 
worms  will  wander  from  the  small  intestines  into  the  stomach  and  irritate 
the  gastric  mucosa.     They  are  frequently  expelled  by  vomiting. 

A  child  4  years  old  was  seen  by  me  during  my  service  at  the  Willard  Parker 
Hospital  in  the  fall  of  1903.  The  child  had  pharyngeal  and  tonsillar  diphtheria.  It 
was  a  septic  type  of  diphtheria.  The  child  vomited  a  round  ivonn  about  6  incJws 
long  on  the  second  day  after  admission.  On  the  tliird  day  another  worm  al)ont  5 
inches  long  was  also  ejected  by  vomiting.  There  were  no  symptoms  pointing  to  the 
presence  of  these  round  worms. 

Some  authors  report  worms  wandering  into  the  nose  and  also  into 
the  middle  ear.  A  worm  entering  the  larynx  has  produced  fatal  asphyxia. 
Another  author  reports  jaundice  due  to  worms  entering  the  common  bile 
duct.  Worms  have  been  known  to  produce  hepatic  abscesses.  They  have 
been  found  in  the  vermiform  appendix.  These  worms  appear  most  fre- 
quently in  the  stools.    They  have  been  found  in  umbilical  abscesses. 

Symptoms. — Very  indefinite  symptoms  can  be  ascribed  to  these  round 
worms.  Irritation,  such  as  restlessness  at  night,  grinding  of  teeth,  picking 
the  nose,  and  scratching  the  anus.  Abdominal  symptoms,  such  as  colic, 
diarrhoea,  and  tympanites  are  frequent.  This  clinical  picture  must  not 
be  presumed  to  be  present  in  all  cases.  Not  infrequently  symptoms  of 
meningitis  will  be  mistaken  for  worms.  Be  sure  to  exclude  all  other  con- 
ditions before  expressing  a  positive  opinion.  Nervous  symptoms  such  as 
hysteria,   vertigo,    and    epileptiform    convulsions   have   been   noted   while 


WORMS.  329 

worms  existed.  As  these  conditions  disappeared  when  the  worms  were 
expelled,  it  is  but  fair  to  presume  that  they  were  indirectly  the  cause  of 
these  nervous  manifestations. 

Diagnosis. — A  positive  diagnosis  can  only  be  made  if  the  round  worms 
are  discharged  from  the  body  or  if  the  ova  is  discovered  in  the  stool.  The 
microscopical  examination,  therefore,  is  very  valuable  and  should  always 
be  made  when  in  doubt.  If  the  ova  are  still  found  in  the  stool  after  one 
or  two  worms  have  been  expelled,  then  more  worms  should  be  suspected. 

Prognosis. — The  prognosis  is  always  good,  but  the  child  must  be  kept 
under  constant  observation  for  at  least  several  months. 

Treatment. — To  eliminate  worms  from  the  body,  the  ttenicide  should 
be  given  for  several  days  <ind  then  followed  by  a  brisk  cathartic.  The  fol- 
lowing formulae  have  served  me  very  well : — 

IJ  JIagnesii  sulphatis 4  drachms 

Syrupi  rubi  id<si 2  fluid  ounces 

M.  Sig.:  A  tablespounful  two  or  three  times  a  week,  to  be  preceded  by 
santonin/  spigelia,  or  chenopodium.  Once  a  day  a  high  enema  of  soapy  water  should 
be  given.  The  folds  of  the  anus  should  be  carefully  cleansed  with  soap  and  water, 
and  the  following  ointment  applied:  — 

IJ  Acidi    boracic    1  drachra 

Olei  rosiB 3  drops 

Vaseline    1  ounce 

M.      Sig.:      'M'P'y  externally. 

Otlier  ta}nicides  recommended  by  Townsend  arc : — 

IJ  Ext.  spigeliie  10  fluid  ounces 

•  Ext.   senna;    6  fluid  ounces 

Olei  anisi   20  minims 

Olei  cari   20  minims 

M.  Sig.:  Half  teaspoonful  for  a  child  2  years  old,  two  or  three  times  daily. 
Teaspoonful  for  a  child  from  4  to  10  years  old. 

Or:— 

R   Oil  of  clicnDpodiuin 2  drachms 

Sig.:      To  be  given  on  sugar  three  times  daily,  in  doses  of  5  drops,  to  a  child  of 

.3  years.      Ten  drops  to  a  child  of   10  years.      A  cathartic  should  be  given  every 

second  or  third  day. 

OxYURis  Vermicularis :     (Pinworm:  Threadworm). 

The  female  worm  is  thin,  yellowish  white,  and  has  a  pointed  tail. 
The  male  has  a  strongly  curved  tail.  The  male  worm  is  rarely  found  in 
the  stool.     The  female  worm  is  present  in  greater  number  than  the  male. 

*  The  formula  for  sant(jnin  is  given  in  the  cliapler  on  "Oxyuris  Vermicularis." 


330  DISEASES  OF  THE  TNTl^.STINES. 

The  oxyuris  is  frequently  passed  in  the  mucus  during  a  catarrhal  discharge 
from  the  rectum.  These  worms  frequently  wander  from  the  rectum  into 
the  vagina. 

Symptoms. — Irritation  and  itching  of  the  anus,  causing  restlessness 
and  severe  nervous  manifestations,  usually  appear  after  the  child  is  in  a 
warm  bed.  The  itching  frequently  gives  rise  to  a  des're  for  frequent 
urination.  In  severe  cases  it  may  lead  to  masturbation.  The  constant 
i^cratching  to  relieve  the  itching  has  produced  vulvitis  and  vaginitis.  Con- 
vulsions have  been  brought  on  by  reflex  irritation  due  to  the  presence 
of  worms. 

Treatment. — Threadworms  are  most  cfTectually  and  easily  removed 
by  the  use  of  enemata.  For  this  purpose  lime  water,  or  an  infusion  of 
quassia,  or  solution  of  common  salt  (a  teaspoonful  of  salt  to  four  ounces 
of  water),  may  be  employed.  In  using  these  agents  the  bowc's  should  first 
be  cleansed  by  a  copious  injection  of  warm  water.  Jacobi  recommends  a 
decoction  of  garlic  as  an  enema  in  these  cases. 

IJ  Santonin    1  to  2  grains 

Mild  ohloriJe  of  mercury V:  grain 

M.  Sig. :  Ever}'  night  for  two  or  tlnee  nights,  to  a  child  5  or  G  years  old, 
and  followed  each  morning  by  a  purgative  dose  of  castor-oil. 

Or:— 

1}  Santonin    1  grain 

Compound  li(|iH)rice  powder 2  drachms 

(Eustace   Smith.) 


CHAPTEE  V. 

DISEASES  OF  THE  RECTUM. 

Fissure  of  the  Anus. 

An  ulcer  having  its  long  diameter  parallel  with  the  long  axis  of  the 
bowel  is  occasionally  met  with.  It  occurs  at  the  anal  margin.  It  is  seen 
in  infants  as  well  as  in  older  children.  It  is  caused  by  the  passage  of 
irritating  hard  faecal  masses.  It  is  also  occasionally  seen  after  prolonged 
diarrhoea  with  continuous  straining.  Some  authors  state  that  traumatism 
from  the  nozzle  of  a  syringe  may  cause  a  fissure.  This  I  have  never  been 
able  to  verify.  Streaks  of  blood  of  a  bright  red  color  will  usually  be  seen 
in  the  stools  when  a  fissure  is  present. 

The  prognosis  is  good. 

Treatment. — This  should  be  mainly  hygienic,  and  consist  in  thorougli 
cleansing  of  the  parts.  The  application  of  solid  nitrate  of  silver  will 
usually  effect  a  cure.  The  bowel  should  be  relieved  daily  by  the  injection 
of  sweet-oil  or  glycerine  to  soften  the  faeces.  Some  authors  advise  stretch- 
ing the  sphincter  of  the  anus  and  keeping  the  parts  at  rest. 

Simple  Catarrhal  Proctitis. 

The  rectum  is  rarely  inflamed  without  additional  portions  of  the 
bowel  being  involved.  When  the  same  exists,  local  causes  must  bo  looked 
for;  for  example,  carelessness  while  irrigating  the  rectum.  Mistakes,  such 
as  corroding  or  caustic  drugs,  can  set  up  an  inflammation.  An  instance 
of  this  kind  occurred  in  my  practice  when  a  child  received  a  strong  injec- 
tion of  carbolic  acid,  causing  inflammation.  Infection  extending  from 
the  vagina  or  urethra,  such  as  gonorrhoja  or  diphtheria,  can  cause  this 
condition.  Syphilis  has  been  known  to  affect  the  rectum.  In  simple  ca- 
tarrh the  pathological  lesions  are  the  same  as  those  found  higher  up  in  the 
gut. 

The  symptoms  are  pain  when  the  bowels  move.  The  stool  contains 
mucus  which  may  be  distinctly  separate.  When  folds  of  mucous  membrane 
protrude  they  are  very  angry  looking  and  show  a  deep  red  pigmentation. 
Children  old  enough  will  complain  of  intense  burning  and  itching. 

The  treatment  consists  in  using  bland  injections  such  as  oatmeal 
water  or  starch  water;  when  severe  tenesmus  exists,  bicarbonate  of  soda, 
a  teaspoonful  to  a  pint  of  water,  is  beneficial. 

(331) 


332  diseases  of  the  recttum. 

Ceoupous  Proctitis. 

This  is  the  form  usually  associated  with  diphtheria  of  the  genitals. 
Large  and  small  pieces  of  mucous  membrane  are  found  mixed  with  the 
stool.  Pathogenic  bacteria,  such  as  the  streptococci  and  staphylococci,  are 
found  in  the  dejecta. 

The  treatment  consists  in  using  bland  antiseptic  irrigations,  bichlo- 
ride of  mercury,  1  to  5000,  or  a  normal  saline  solution,  repeated  several 
times  a  day.  If  diphtheria  is  present,  antitoxin  should  be  given  (see 
chapter  on  "Antitoxin"). 

If  syphilis  is  present  the  usual  treatment  for  the  same  (see  chapter 
on  "Syphilis")  is  indicated. 

Ulcerative  Proctitis. 

Tuberculous  ulceration  of  the  rectum  has  been  reported  by  Steffen; 
also  by  Holt.  Syphilitic  ulcers  are  rare  in  children.  There  is  usually 
bleeding  and  tenesmus.  The  blood  is  of  a  bright  red  color.  The  diagnosis 
is  easily  made  by  examination  with  a  speculum  and  by  no  other  means. 

The  treatment  is  very  difficult.  First,  cleanse  the  rectum.  Apply, 
locally,  nitrate  of  silver  with  the  aid  of  a  speculum.  The  insufflation  of 
iodoform,  dermatol,  or  europhen  is  very  practical. 

HEMORRHOIDS. 

This  condition  is  occasionally  met  with  in  children.  It  usually  ac- 
companies chronic  constipation.  The  persistent  constipation  associated 
with  cretinism  occasionally  causes  this  condition. 

An  instance  of  this  kind  was  seen  by  me  in  a  child  about  2  Vi  years  old,  which 
was  referred  to  me  because  it  could  neither  walk  nor  talk.  It  had  been  operated 
for  congenital  adenoids  by  Dr.  W.  Freudenthal.  The  case  had  been  under  the  treat- 
ment of  Dr.  A.  Jacobi  for  one  year.  In  this  case  chronic  constipation  was  associated 
with  haemorrhoids.  The  stool  was  so  hard  and  dry  that  blood  was  occasionally 
found  after  severe  tenesmus.  Thyroid  treatment  was  directed  against  the  cretinism, 
and  malt  extract  ordered  to  overcome  the  constipation. 

The  usual  treatment  consists  in  removing  the  cause  as  much  as  pos- 
sible as  above  described. 

I  have  never  met  with  a  case  under  12  years  of  age  that  required 
operation,  although  instances  of  this  kind  are  occasionally  described  in 
surgical  literature. 

ISCHIO-RECTAL  AbSCESS. 

In  excoriated  conditions  around  the  anus,  following  continued  diar- 
rhoea, an  infection  frequently  results  from  scratching.  Pyogenic  bac- 
teria undoubtedly  enter  the  lymph  channels. 


PROLAPSUS  ANL  833 

A  case  of  this  kind  was  seen  by  me  in  the  family  of  Dr.  J.  Grosner,  of  New 
York  City.  An  infant  nursing  at  the  breast  had  dyspeptic  symptoms,  such  as  flatu- 
lence, and  later,  intestinal  catarrh.  An  ischio-rectal  abscess  developed  later  on.  It 
was  benign  and  required  a  simple  incision  with  careful  attention  to  asepsis.  This 
condition  lasted  in  all  about  two  weeks.      The  child  made  a  splendid  recovery. 

At  times  we  meet  with  very  deep-seated  inflammation  which  requires 
the  skill  of  the  surgeon.  When  a  fistula  exists  proper  surgical  treatment  is 
indicated. 

Prolapsus  Ani. 

When  children  strain,  especially  during  constipation,  prolapse  of  the 
anus  frequently  follows.  Not  infrequently  as  much  as  one  or  two  inches 
of  the  mucous  membrane  protrudes.    (See  Fig.  122.) 

Causes. — There  are  three  main  causes:  First,  weakness  of  the  levator 
ani  muscles.  In  general  atonic  conditions — for  example,  in  rickets — this 
condition  frequently  follows  constipation,  the  constipation  being  a  part 
of  the  rickety  condition  and  indirectly  causing  a  straining  during  defeca- 
tion, thus  ending  in  prolapse  of  the  rectum.  Deficient  peristalsis,  espe- 
cially in  young  children,  induces  them  to  strain  to  expel  hardened  fsecal 
matter.  On  the  other  hand  constant  diarrhoea  and  irritation  in  the  lower 
bowel  may  also  result  in  prolapse.  When  an  attack  of  summer  complaint 
has  lasted  a  long  time,  we  usually  find  at  the  end  of  defecation  that  the 
rectum  protrudes. 

Second,  when  the  ischio-rectal  fat  is  deficient.  In  marasmic  condi- 
tions, such  as  in  athrepsia  infantum  or  following  the  acute  infectious  dis- 
eases, when  high  fever  and  general  wasting  has  taken  place,  the  body  fat 
suffers,  and  so  the  mechanical  support  of  the  rectum  is  lost. 

Third,  traumatic  condition.  This  condition  is  frequently  induced 
by  coughing  paroxysms,  hence  it  not  infrequently  follows  whooping-cough. 
Eetention  of  urine,  phimosis,  and  vesical  calculi  may  cause  this  condition. 

Diagnosis. — The  size  and  the  location  of  the  tumor,  and  its  appear- 
ance during  the  straining  while  at  stool,  renders  the  diagnosis  easy.  The 
ease  with  which  the  prolapse  can  be  replaced  is  noteworthy  in  making  a 
diagnosis.  It  is  rare  for  this  condition  to  be  mistaken  for  intussusception 
(see  chapter  on  "Intussusception").  A  polypoid  growth  is  usually  found 
independent  of  the  straining  during  defecation. 

Treatment. — Local:  Place  the  child  in  the  knee-chest  position  and 
apply  olive-oil  to  the  prolapsed  bowel,  after  which  the  gut  can  be  replaced. 
When  this  mild  manner  of  reduction  is  not  successful,  a  whiff  of  chloro- 
form should  be  used  to  quiet  the  child.  This  will  also  relax  the  protruding 
part.  After  replacing  the  gut  the  buttocks  should  be  supported  by  a  stout 
strap  of  adhesive  plaster  running  from  side  to  side.  Cold  water  irrigations 
should  be  given.     These  will  have  the  two-fold  object  of  emptying  the 


334  DISEASES  OF  THE  RECTUM. 

lower  bowel  as  well  as  toning  the  muscle.  Astringent  injections  of  sulphate 
of  zinc,  1  grain  to  the  ounce,  or  tannic  acid,  10  grains  to  the  ounce,  are 
recommended  by  some.  I  have  failed  to  see  any  benefit  therefrom.  The 
local  application  of  the  tincture  of  the  chloride  of  iron  once  every  three 
days,  has  seemed  to  be  of  some  benefit.  The  solid  stick  of  nitrate  of  silver 
or  cauterization  by  means  of  the  Paquelin  cautery,  made  red  hot,  is  fre- 
quently recommended.  Heroic  measures,  such  as  amputation  of  the  parts, 
are  rarely,  if  ever,  necessary. 

Constitutional  Treatment. — We  must  not  expect  to  cure  a  condition 
of  this  kind  unless  the  body  is  strengthened.  Restoratives,  cereals,  eggs, 
and  milk  must  be  prescribed.  We  can  supply  a  deficiency  of  fat  by  order- 
ing codliver-oil  or  lipanin,  1  teaspoonful  three  times  a  day.  When  con- 
stipation exists  the  addition  of  malt,  as  in  a  malted  food,  will  aid  this 
condition.  Strychnine  may  be  given  in  doses  of  Vioo  of  a  grain,  and 
increased  gradually  until  Vgo  of  a  grain  is  given,  three  times  a  day.  Iron 
can  also  be  given  with  great  advantage.  Massage  of  the  abdomen  and 
electricity  must  not  be  forgotten.  A  cold  shower  or  spray  over  the  spine 
and  abdomen,'  repeated  every  day,  is  an  excellent  tonic. 


I 


CHAPTER  VI. 

DISORDERS  RESULTING  FROM  lilPROPER  NUTRITION 
( DISTURBED  IMETABOLISM ) . 

Scurvy  (Scorbutus:  Barlow's  Disease). 

This  is  a  constitutional  disease  resulting  from  improper  feeding. 

Etiology. — It  usually  occurs  before  the  end  of  the  second  year,  and 
rarely  occurs  before  the  first  six  months  of  a  child's  life.  As  in  adults, 
scurvy  is  found  when  fresh  food  has  been  withdrawn  from  the  dietary.  It 
is  natural,  therefore,  to  look  for  scorbutic  cases  among  children  who  are : — 

First,  deprived  of  breast-milk. 

Second,  in  those  brought  up  exclusively  on  milk  which  is  devitalized  by 
'prolonged  sterilization. 

Third,  it  is  found  in  children  brought  up  on  condensed  milk  and  on 
those  proprietary  foods  to  which  fresh  milTc  has  not  been  added.  There 
seems  to  be,  therefore,  a  direct  relationship  between  the  absence  of  fresh 
milk,  be  it  cows'  milk  or  human  milk,  and  the  development  of  this  disease. 
It  is  a  great  mistake  to  attach  importance  to  the  fact  that  an  infant  was 
fed  on  a  proprietary  food  unless  we  know  whether  or  no  fresh  milk  was 
added.  It  is  the  absence  of  the  live  factor  in  fresh  milk  which  directly 
causes  scurvy. 

Troup,  of  Christiana,  quoted  by  Koettlitz,^  is  strongly  of  the  opinion 
that  scurvy  is  the  result  of  a  scorbutic  element  of  the  nature  of  a  ptomaine 
present  in  the  diet.  Jackson  and  Vaughan  Harley,^  as  a  result  of  an 
experimental  inquiry  into  scurvy,  arrived  at  much  the  same  conclusion. 
The  question  under  discussion  here  is  whether  or  not  infantile  scurvy  is 
the  result  of  the  absence  of  some  essential  element  in  the  diet  or  the  pres- 
ence of  some  scorbutic  factor.  It  is  certain  that  an  infant  fed  for  a  long 
period  upon  peptonized  milk,  will  develop  scurvy,  but  if  potato  gruel  and 
raw  meat  juice  are  added,  yet  no  other  alteration  made  in  the  diet  and  no 
medicine  given,  the  scurvy  will  rapidly  disappear  and  the  child  be  well 
in  a  few  weeks.  Thus  the  addition  of  a  fresh  element  to  the  scurvy  diet 
has  cured  the  condition.  Moreover,  many  of  the  diets,  for  example,  oat- 
meal and  water,  upon  which  the  young  children  become  scorbutic,  seem 
to  exclude  the  possibilities  of  the  development  of  ptomaines.  The  experi- 
ments of  Jackson  and  Harley  do  not  carry  conviction  that  true  scurvy 
has  been  produced  in  animals,  but  rather  that  a  condition  of  ptomaine 
poisoning  has  resulted.     It  is  possible  that  unsound  food  may  hasten  the 


>  Guy's  Hosp.  Gazette,  March  30,  1901. 
*  Proceedings  Royal  Society,  March,  1900. 

(335) 


336  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

development  of  scurvy,  but  the  evidence  at  present  seems  insufficient  to 
invalidate  the  conclusion  that  infantile  scurvy  is  due  to  the  absence  of 
an  anti-scorbutic  element  rather  than  to  the  presence  of  some  scorbutic 
poison. 

Summary  of  Essential  Conditions. — The  six  essential  conditions  to  be 
observed  in  the  diet  of  infants,  are  these: — 

1.  The  food  must  contain  the  different  elements  in  the  proportions 
which  obtain  in  human  milk,  viz.: — 

Proteid   1.5  per  cent. 

Fat    3.5  per  cent. 

Carbohydrate    6.5  per  cent. 

Salts 2  per  cent. 

Other  constituents 6  per  cent. 

Water 87.7  per  cent. 

100.0 

2.  It  must  possess  the  anti-scorbutic  element. 

3.  The  total  quantity  in  twenty-four  hours  must  be  such  as  to  rep- 
resent the  nutritive  value  of  1  to  3  pints  of  human  milk,  according  to 
age,  viz. : — 

Proteid 225  to     675  grains 

Fat  231  to      693  grains 

Carbohydrates  613  to    1839  grains 

4.  It  must  not  be  purely  vegetable,  but  must  contain  a  large  propor- 
tion of  animal  matter. 

5.  It  must  be  in  a  form  suited  to  the  physiological  condition  of  the 
digestive  function  in  infancy. 

6.  It  must  be  fresh  and  sound,  free  from  all  taint  of  sourness  or 
decomposition. 

Pathology. — Hsemorrhages  in  and  around  the  joints  and  in  the  mus- 
cles are  found  post-mortem.  The  most  important  point,  however,  is  the 
presence  of  subperiostial  haemorrhage  involving  the  long  bones.  Eotch 
states  that  the  femora  are  the  most  commonly  affected,  and  that  there  is 
a  tendency  to  a  separation  of  the  epiphyses.  Interstitial  haemorrhage  in- 
volving the  lungs,  spleen,  kidneys,  and  interstitial  glands  have  been  found. 
When  the  kidneys  are  involved  we  can  usually  find  haematuria.  Haemor- 
rhages are  frequently  present  in  the  mucous  surfaces;  thus  the  gums  show 
a  deep  purple  color,  besides  being  swollen  and  preefcnting  the  character- 
istic spongy  appearance. 

We  are  indebted  to  Barlow  for  his  valuable  studies  regarding  the 
pathology  and  symptomatology  of  this  disease.  The  blood  shows  no  specific 
changes  which  are  pathognomonic  to  this  disease. 


SCURVY.  837 

Bacteriolo^. — No  specific  bacterium  has  as  yet  been  found  nor  does 
the  blood  show  any  peculiarities  bacteriologically. 

Symptoms  and  Diagnosis. — The  symptoms  are  marked  irritability  by 
day  and  restlessness  at  night,  associated  with  insomnia.  The  mother  or 
nurse  will  usually  say  that  the  child  cannot  be  satisfied  and  cries  when- 
ever touched,  most  especially  when  the  arms  and  legs  are  moved.  It  is 
very  apparent  that  there  is  pain  due  to  a  swelling  of  the  limbs,  usually 
of  the  diaphyses  just  above  the  epiphyses.  When  not  disturbed  these 
children  seem  to  lay  quietly.  Swelling  of  the  limbs  in  the  legs  and  fore- 
arm is  usually  present.  While  the  skin  over  the  swelling  is  tense  there  is 
no  evidence  of  fluctuation.  Tenderness  on  pressure  is  usually  noted. 
Bluish-black  spots,  due  to  small  subcutaneous  hsemorrhages,  are  visible. 
When  hsemorrhages  affect  the  deeper  parts  around  the  eyes  so  that  the  eye 
itself  will  be  pushed  forward,  a  condition  called  proptosis  will  be  noted. 
This  condition  of  proptosis  is  found  in  advanced  cases  of  scurvy. 

Owing  to  pain  in  the  limbs  the  child  does  not  appear  to  move,  giving 
rise  to  the  impression  that  the  child  is  paralyzed.  When  this  condition 
is  seen  in  scurvy  it  has  been  called  pseudo-paralysis.  The  gums  are  very 
spongy  and  swollen,  and  have  bluish  maculae  over  the  surfaces.  .  The  child 
shows  the  evidences  of  marked  anaemia  and  loss  of  weight.  There  is  loss 
of  appetite,  and  when  food  is  taken  the  head  perspires  freely.  The  tem- 
perature rises  in  the  evening  to  between  101°  and  102°  F.  The  pulse  is 
small,  feeble,  and  ranges  between  120  and  140.  The  respirations  are  not 
afl'ected.  The  clinical  picture  is  one  of  marked  malnutrition  with  symp- 
toms simulating  tuberculosis. 

This  disease  is  liable  to  occur  in  either  sex;  it  is  not  influenced  by 
climate  or  locality;  it  is  foimd  as  well  in  the  best  as  in  the  poorest  hygienic 
surroundings.  By  far  the  greatest  number  of  cases  is  found  among  the 
rich.  It  is  evident  that  this  disease  is  due  to  improper  feeding  more  than 
to  an  improper  h^'giene.  Some  authors  believe  that  this  disease  is  caused 
by  a  specific  micro-organism;  this  latter  fact  has  not  yet  been  definitely 
settled. 

It  is  interesting  to  note  the  various  views  expressed  by  competent 
observers  upon  this  subject;  thus,  while  a  large  majority  of  clinicians 
hold  that  sterilized  milk  per  se  does  cause  scurvy,  Eotch  states  that  it  does 
Eot,  in  his  own  experience,  seem  to  do  so.  Starr  maintains  just  the  reverse 
and  believes  that  sterilized  milk  is  a  causative  factor.  From  my  own  ex- 
perience I  quite  agree  that  sterilized  milk — especially  the  prolonged  ster- 
ilization, by  which  the  albumins  are  changed,  and  by  which  this  prolonged 
heating  causes  devitalization,  which  is  so  inimical  to  successful  feeding — ia 
a  causative  factor  in  this  disease. 

It  is  peculiar  that  scurvy  will  be  cured  by  giving  raw  milk,  fresh 
fruits,  and  acid  fruits;    still  we  find  that  a  great  many  clinicians  per- 


338  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

sist  in  prescribing  sterilized  milk  until  either  rickets  or  scurvy  is  estab- 
lished. It  was  for  this  reason  that  at  a  discussion  on  infant  feeding  at 
the  Academy  of  Medicine,  October  18,  1900,  I  was  led  to  insist  on  the  use 
of  raw  milk  as  the  proper  means  of  feeding  children.'^ 

Eaw  milk  possesses  certain  advantages  over  boiled  milk;  it  is  more 
readily  assimilated  and  the  proteids  are  not  so  difficult  to  digest.  It  is  a 
well-known  fact  that  boiled  milk  and  sterilized  milk  have  a  tendency  to 
produce  constipation,  whereas  the  opposite  is  true  of  raw  milk. 

Improper  infant  food  has  additional  disadvantages  when  it  is  sub- 
jected to  excessive  heating.  The  large  number  of  failures  with  milk  modi- 
fied at  a  laboratory  are  not  so  much  due  to  the  process  involved  in  the 
modification  as  to  the  amount  of  heat  that  the  food  is  subjected  to  prior 
to  being  imbibed. 

Where  milk  is  modified  for  infant  feeding,  using  raw  milk  only,  1 
have  never  seen  constipation;  the  reverse,  however,  has  always  been  true 
when  milk  was  modified  and  then  subjected  to  sterilization.  The  vital 
point  has  always  impressed  me  as  being,  not  so  much  to  sterilize  milk  after 
it  has  been  drawn  from  the  cow,  but  to  apply  the  principle  of  sterilization 
to  the  stable,  the  cow,  the  utensils,  the  milker's  hands,  and  to  everything 
coming  in  contact  with  the  milk  from  the  time  it  leaves  the  cow's  udder 
until  it  is  fed  to  the  baby. 

When  oatmeal  gruel  or  barley  gruel  is  given  with  an  insufficient  quan- 
tity of  cows'  milk  and  then  fed  for  a  long  time,  we  mv^t  not  be  surprised 
to  find  a  case  of  scurvy.  When  proprietary  foods  are  given  without  the 
addition  of  fresh  milk,  then  scurvy  will  usually  result.  When  cream 
mixtures  are  given  which  are  deficient  in  fat  and  proteids,  then  scurvy 
may  result.  Thus  we  find  that  the  true,  underlying  cause  of  scurvy  is 
starvation  due  to  deficiency  of  one  or  more  nutritive  elements  in  the  food 
given. 

The  following  case  of  scurvy  will  illustrate  the  condition : — 

A  child  thirteen  months  old  was  brought  to  me  with  a  history  of  being  very 
restless  and  having  lost  considerable  weight.  The  child  showed  a  shriveled  appear- 
ance of  the  skin;  its  normal  elasticity  was  gone;  the  skin  was  dry;  the  thorax  was 
pigeon-breasted;  the  arms  and  legs  were  thin;  both  arms  and  legs  showed  marked 
tenderness  on  the  slightest  motion;  there  was  baldness  at  the  occiput,  and  the 
anterior  fontanel  was  not  closed;  the  child  had  eight  teeth,  all  of  which  were  slightly 
carious;  the  gums  around  the  teeth  were  deeply  congested  and  showed  bluish  ridges; 
the  gums  were  spongy  and  bled  very  easily;  there  was  an  intense  foetor  to  the 
breath;  the  child  had  been  suffering  from  diarrhoea  for  the  past  two  months,  with 
occasional  periods  of  constipation;  there  was  no  vomiting;  the  appetite  had  always 
been  very  poor.  The  previous  history  of  the  child  was  that,  when  born,  it  weighed 
about  5  pounds;    it  was  very  small  at  birth.     The  mother  of  the  child  died  during 


•  Read  also  my  chapter  on  "Scurvy,"  in  the  Third  Edition  of  "Infant  Feeding 
in  Health  and  Disease."      Published  by  F.  A.  Davis  Company,  1904. 


SCURVY.  339 

confinement,  and  hence  the  baby  was  given  into  the  care  of  a  nursery.  The  diet 
consisted  of  1  teaspoonful  of  condensed  milk  with  12  teaspoonfula  of  water  and  a 
small  pinch  of  sugar.  This  was  fed  every  two  hours  for  a  period  of  over  two  months; 
later  the  child  was  put  on  barley  water,  to  which  some  condensed  milk  was  added. 
This  was  changed  from  time  to  time  to  a  diet  of  oatmeal  water  and  condensed  milk. 

The  child  had  always  been  frail,  and  had  had  a  cough  and  also  an  attack 
of  acute  capillary  bronchitis;  during  the  summer  the  child  had  a  severe  attack  of 
cholera  infantum,  and  almost  lost  its  life  from  vomiting  and  purging.  For  one 
month  this  child  subsisted  on  a  diet  of  oatmeal  water,  rice  water,  farina  water,  and 
albumin  water,  besides  cold  tea.  Thus  it  is  seen  that  the  child  received  no  milk  for 
a  period  of  over  seven  weeks.  When  the  child  was  five  months  old  it  weighed  7 
pounds,  and  at  this  time  it  hardly  weighs  10  pounds.  There  is  a  marked  rachitic 
kyphosis;  the  ribs  are  beaded;  there  is  a  pendulous  belly;  the  child  has  an 
umbilical  hernia;  the  temperature,  taken  in  the  rectum  at  2  p.m.  for  a  period  of 
at  least  two  weeks,  was  no  higher  than  100°  to  101"  F.;  there  is  an  intense  thirst;  the 
kidneys  are  very  active;  the  urine  has  a  very  high  color;  no  hsematuria  could  be 
found. 

The  diagnosis  of  infantile  scurvy  was  made  and  the  child  was  put  on  the  follow- 
ing treatment:  Orange  juice;  lemonade;  freshly-expressed  steak  juice;  raw  milk> 
diluted  with  barley  water  or  rice  water,  equal'  parts  (4  ounces  of  milk,  4  ounces  of 
barley  water),  repeated  every  three  or  four  hours,  depending  upon  the  appetite. 
Massage  of  the  body  was  very  gently  performed  with  codliver-oil  or  vaseline,  to 
lubricate  and  to  nourish.  A  1-drop  dose  of  nux  vomica  was  ordered  before  each 
feeding.  This  treatment  was  given  continually  for  three  or  four  weeks.  Every 
fourth  or  fifth  day  a  half-ounce  of  barley  water  or  rice  water  was  withdrawn,  and 
instead  an  equal  quantity  of  fresh  milk  was  added;  hence,  after  four  weeks  ol 
treatment  this  child  received  6  ounces  of  milk  with  2  ounces  of  barley  water  or  rice 
water  every  four  hours. 

The  child  was  sent  to  the  seashore,  and  after  this  treatment  was  continued  for 
seven  months  all  symptoms  of  scurvy  had  disappeared,  though  the  symptoms  of 
rickets  were  still  very  prominent.  The  prognosis  now  is  very  good,  and  the  child 
will  undoubtedly  recover. 

When  children  have  walked,  and  suddenly  stop  walking  and  will  not 
creep,  then  attention  should  be  directed  to  the  state  of  the  gums  and  to 
the  general  physical  condition.  Such  cases  are  usually  suspicious,  and 
show  the  beginning  of  the  development  of  scurvy.  Indeed,  such  symptoms 
will  develop  long  before  there  is  a  general  breaking-down.  Emaciation 
and  anorexia  follow,  which  are  associated  in  this  condition. 

Differential  Diagnosis. — From  Rickets:  This  condition  is  easily  dif- 
fereotiated.  In  scurvy  there  is  no  rachitic  rosary.  There  are  no  haemor- 
rhages involving  the  gums  nor  spongy  swellings  found  in  rickets.  The 
pendulous  belly  is  usually  not  seen  in  scurvy,  neither  is  the  rachitic  square 
head  frequently  seen. 

From  Tuberculosis. — The  absence  of  cough  and  other  physical  signs  in 
the  thorax  common  to  tuberculosis  besides  the  absence  of  the  symptoms 
above  mentioned  common  to  scurvy,  will  differentiate  this  condition  from 
tuberculosis. 


340  DISORDERS  RESULTING  FROM  IIMPROPER  NUTRITION. 

Scurvy  and  Rickets. — Both  diseases  may  be  found  at  the  same  time 
in  the  child,  and  are  evidently  due  to  disturbances  of  metabolism  founded 
upon  dietetic  errors  in  which  the  absence  of  the  live  factors  in  food  have 
been  neglected. 

Prognosis  and  Course. — The  course  of  the  disease  is  usually  chronic. 
I  have  seen  cases  of  scurvy  wasted  to  skin  and  bone,  when  hardly  any  mus- 
cle was  left,  and  the  fat  almost  gone  and  the  elasticity  of  the  skin  lost. 
In  spite  of  this  shriveled  condition,  with  proper  feeding,  in  a  few  months' 
lime,  wonderful  changes  were  made.  I  do  not  regard  a  case  of  scurvy  as 
hopeless  if  some  vitality  remains.  We  must  be  exceedingly  persistent  and 
patient,  and  continue  the  treatment  for  weeks  and  months. 

Treatment. — The  most  important  part  of  the  treatment  of  scurvy  con- 
sists in  eliminating  the  antiscorbutic  elements  by  proper  feeding. 

■  Dietetic  Treatment. — Antiscorbutic  diet  consists  of  fresh  milk,  fine 
potato  gruel,^  raw  meat,  raw  yolk  of  Qgg,  orange  Juice,  and  sugar. 

Fresh  milk  is  clearly  not  a  potent  antiscorbutic,  and  although  suf- 
ficient to  prevent  scurvy  when  given  in  full  quantity,  will  not  always  pre- 
vent it  when  taken  in  small  amounts  only.  It  fails  accordingly  to  remove 
the  scorbutic  condition  with  quickness  and  certainty  when  given  alone. 
It  is  necessary,  therefore,  to  add  to  the  food  some  more  active  agent,  such 
as  potatoes,  carrots,  or  a  vegetable  juice,  as  orange  juice,  Malaga  grapes, 
or  a  broth  in  which  vegetables,  such  as  carrots  and  potatoes,  have  been 
boiled  and  strained,  with  raw  meat  juice  in  addition. 

In  addition  to  the  rigid  enforcement  of  the  above-mentioned  foods, 
we  must  insist  upon  fresh  air. 

Hygienic  Treatment. — Besides  having  fresh  air,  a  child  suffering  with 
scurvy  must  be  put  directly  into  the  sun.  This  sun  bath  should  be  admin- 
istered for  hours  at  a  time.  Proper  ventilation  of  the  sleeping  apartment 
is  very  important.  A  scorbutic  child  requires  a  daily  bath  consisting  of 
one  pound  of  sea  salt  to  a  tub  of  water  at  a  temperature  of  95°  F.  The 
child  should  be  bathed  from  three  to  five  minutes  and  rubbed  briskly  while 
in  the  tub.  After  the  bath  the  body  should  be  dried  with  a  coarse  towel 
and  rubbed  until  the  skin  has  a  pinkish  color.  This  friction  or  massage 
is  very  invigorating,  and  if  done  in  the  evening  it  will  promote  sleep  and 
soothe  the  child. 

Medicinal  Treatment. — Eestoratives,  such  as  pure  codliver-oil,  lipa- 
nine,  or  morrholine,  given  in  doses  of  a  teaspoonful  two  or  three  times  a 
day,  is  indicated.    Iron,  such  as  syrup  of  the  iodide,  10  to  30  drops,  three 


'Prepared  by  rubbing  thoroughly  steamed  floury  potato  through  a  fine  sieve, 
and  beating  this  up  well  with  milk  until  it  is  smooth  and  of  the  consistency  of  thin 
cream.  A  teaspoonful  of  this  may  be  added  to  each  bottle  at  first,  and  the  amount 
gradually  increased  to  a  dessertspoonful,  if  it  is  found  to  agree.  Well-boiled  carrots 
may  be  used  in  the  same  way. 


RACHITIS.  841 

times  a  day,  or  tincture  ferri  acetic  ether,  10  to  20  drops,  three  times  a 
day,  may  be  given.  Malt  extract  contains  a  live  factor,  and  is  therefore 
very  valuable  as  an  antiscorbutic  restorative;  it  should  be  given  in  doses 
of  a  teaspoonfu],  two  or  three  times  a  day,  or  until  the  bowels  are  loose,  then 
the  dose  must  be  reduced. 

Maltine  is  one  of  our  best  preparations  and  has  served  me  very  well 
in  scurvy.  The  successful  outcome  of  the  treatment  of  a  case  of  scurvy 
depends  on  judicious  feeding  aided  by  the  above-named  associated  con- 
ditions. 

Rachitis  (Eickets). 

Eickets  is  a  disorder  of  nutrition.  It  occurs  chiefly  between  the  ages 
of  six  months  and  2  years.  Congenital  rickets  is  occasionally  seen.  It 
affects  the  bones  primarily,  and  these  are  very  readily  distinguished  during 
life.  The  disease  also  affects  the  ligaments,  the  mucous  membrane,  the 
muscles,  and  especially  the  nervous  system. 

Pathology. — The  lesions  are  chiefly  noticed  in  the  bones,  although 
the  soft  tissues  show  evidences  of  anaemia.  The  primary  lesion  is  hyper- 
emia of  the  periosteum,  the  marrow,  the  cartilage,  and  the  bone.  The 
spleen  ajid  liver  are  usually  enlarged.  Frequently  we  note  enlargement  of 
the  lymphatic  glands. 

Starck  found  the  spleen  enlarged  in  50  per  cent,  of  his  autopsies  in 
rachitic  children,  and  in  68  per  cent,  of  all  his  living  cases.  In  the  kid- 
neys there  are  usually  no  pathological  lesions.  The  cartilage  cells  of  the 
epiphyses  undergo  increased  proliferation  from  four  to  ten  times  more 
than  they  do  in  a  normal  growing  bone.  The  matrix  is  softer;  as  a  result 
the  bone  formed  from  this  abnormal  cartilage  lacks  firmness  and  rigidity. 

The  increased  proliferation  of  cells  makes  the  epiphysis  larger,  swollen 
in  appearance,  irregular  in  outline,  and  much  softer  in  consistence.  It  has 
been  experimentally  proven  that  hyperemia  of  bone  causes  defective  de- 
compositions of  lime  salts.  Owing  to  this  deficiency  of  lime  salts  the  bones 
become  very  soft  and  flexible.  While  normally  there  is  two-thirds  mineral 
matter  in  the  bones,  in  rickets  this  is  reduced  to  one-third.  Thus  we  can 
easily  explain  the  various  "rachitic  deformities"  which  are  especially  noted 
in  the  femur,  the  tibia,  the  radius,  the  ulna,  and  the  ribs.  When  ossifica- 
tion is  retarded  during  rickets,  as,  for  example,  in  the  parieto-occipital 
region,  the  bone  is  frequently  so  thin  that  it  yields  to  pressure,  this  is 
called  craniotabes. 

The  fontanels  are  not  closed  until  very  late  owing  to  this  delayed 
ossification.  The  frontal  and  parietal  protuberances  are  very  much  en- 
larged, due  to  exaggerated  proliferation  of  the  periosteum,  so  that  the 
head  acquires  a  broad  forehead  with  characteristic  frontal  prominence. 
This  condition  is  frequently  taken  for  hydrocephalus.     When  ossification 


342 


DISORDERS  RESULTING  FROM  LMPROPER  NUTRITION. 


takes  place  the  bones  become  large,  heavy,  and  irregular  in  outline,  corre- 
sponding to  the  clinical  manifestations  known  as  "bow-legs,"  "knock- 
knees,"   "pigeon-breast,"   "spinal   curvature,"   and    "square   cranium." 

Where  the  bone  joins  the  cartilage,  as,  for  example,  on  the  ribs,  en- 
largements occur  which  simulate  beads;   hence  the  term  "beaded  ribs,"  also 


1 


Fig.  92. 


Fig  93. 


Fig.  92. — Case  of  Hydrencephaloid  (Spuriou.s  Hydrocpphaliis).  Infant 
8  months  old.  Bottle-fed.  Suffering-  with  eliolera  infantum.  Severe  nervous 
and  toxic  symptoms, 

Fig.  {).3. — Same  Child  Tavo  Years  Later.  Note  the  square  head,  the 
frontal  protuberance.  Also  the  Harrison's  groove  and  tlie  pendulous  belh^ 
The  picture  illustrates  the  cranial,  thoracic  and  abdominal  type  of  rickets. 
(Original.) 


called  "rachitic  rosary."     The  same  enlargements  can  be  felt  at  the  wrists, 
ankles,  and  knees. 

A  section  through  the  epiphyseal  junction  of  a  rachitic  bone  shows  a 
very  vascular,  bluish-colored  condition,  which  is  softer  than  normal  when 
cut.  In  the  shaft  next  to  the  periosteum  the  bone  is  soft  and  thickened, 
but  deeper  it  is  hard.  Sections  through  thickened  masses  on  the  flat  bones 
show  a  spongy  vascular  substance  which  is  soft  enough  to  be  indented 
easily. 


RACHITIS. 


343 


Microscopical  examinatimi  shows  a  marked  increase  in  new  cartilage 
cells  and  increased  vascularity  of  the  proliferating  zone.  The  areas  which 
should  be  calcified  show  large  quantities  of  cartilaginous  tissue  instead. 
The  under-layer  of  the  periosteum  is  very  vascular,  and  again  there  is  a 
great  excess  of  imcalcified  cartilage.  In  the  flat  bones  the  bony  trabeculae 
are  eroded,  and  their  places  taken  by  newly  formed  minute  blood-vessels. 

When  the  rachitic  process  ceases  and  recovery  begins,  this  excessive 
proliferation  stops.  Calcification  and  ossification  of  these  tissues  take 
p'ace;  the  enlargements  due  to  the  hyperplasia  are  absorbed,  and  the  bone 
returns  to  a  normal  condition  save  for  any  deformities  that  may  have  re- 
sulted during  the  activity  of  the  rachitic  process. 


Fig.  9-1 — A  Case  of  Spurious  Ilvdroeephalus,  Iliustrating  Marked  Fron- 
tal and  Parietal  Protuberances.  There  was  a  striking  resemblance  to  a 
case  of  liydroc-eplialus.     Bottle-fed.     Pvachitic.      (Original.) 


Chidren  that  have  suffered  prolonged  diarrhocc^s  or  with  severe  dis- 
eases— like  dysentery,  typhoid,  Ijronchitis,  and  pneumonia — are  prone  to 
the  development  of  rickets.  Children  of  syphilitic  parents  and  those  whose 
parents  are  tuberculous  are  more  prone  to  the  development  of  this  disease. 
Von  Eitter,  quoted  by  Professor  Baginsky,  says  that,  in  27  cases  out  of  71 
examined  by  him,  rickets  was  not  only  found  in  the  children,  but  as  well 
in  the  mothers  of  these  same  cases.  Thus  it  is  that  Kassowitz  and  Schwarz^ 
have  mentioned  the  existence  of  congenital  rickets.  These  same  authors 
found  tliat  80  per  cent,  of  children  bom  in  the  Vienna  Lying-in  Hospital 
were  rachitic.     This  statement  is  not  so  easily  accepted,  however,  for  neither 

^Wiener  medicinische  Jahrbuclier,  1S.S7,  vol.  viii. 


344  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

Professor  Baginsky  nor  Virchow  accept  the  same.  Experimentally,  it  has 
been  found  as  long  ago  as  1842  by  Chossat  that  when  lime  is  deducted 
from  the  nourishment  of  young  animals  not  only  soft  bones  result,  but  they 
finally  die.  Heitzmann  maintains  that,  if  lactic  acid  is  introduced  into 
the  food  of  young  animals,  the  result  will  be,  first,  rickets,  and,  later 
on,  osteomalacia  will  result  therefrom.  Clinical  investigations  have  shown 
that  cases  of  rickets  occur  more  often  during  the  winter  months;  thus  it 
is  apparent  that  improper  ventilation  is  one  of  the  most  exciting  causes  of 
this  disease. 

When  children  are  improperly  fed  so  that  the  body  is  underfed,  mus- 
cle and  bone  formation  will  be  slow.  The  eruption  of  the  teeth  will  be 
delayed,  and  this  is  one  of  the  most  prominent  symptoms  of  rickets.  The 
bones  show  the  most  characteristic  result  of  improper  nutrition,  for  they 
are  very  soft  and  spongy.  They  will  yield  to  the  weight  of  the  body  if  used 
in  walking,  and  thus  it  is  that  bow-legs  with  extensive  curvatures  form 
such  a  prominent  feature  in  showing  the  result  of  using  soft  bones.  The 
most  typical  symptoms  can  be  studied  on  the  head  and  spine.  Thus, 
craniotabes  can  be  explained  by  a  deficient  nutrition  in  which  the  cranial 
bones  will  be  found  so  soft  that  they  will  yield  to  the  pressure  of  the  thumb. 
The  cranial  bones  will  frequently  be  found  to  be  as  soft  and  as  thin  as  paste- 
board. The  spine  is  frequently  deformed,  and  will  show  a  typical  rachitic 
kyphosis. 

Causes. — The  absence  of  human  milk  from  the  diet  of  an  infant  is 
one  of  the  prime  reasons  for  the  development  of  rickets.  We  therefore  find 
more  than  90  per  cent,  of  all  cases  of  rickets  among  the  bottle-fed  babies. 
Other  contributing  factors  are  the  absence  of  sunshine  and  the  crowding 
of  large  families  into  small  rooms  having  poor  ventilation.  Eickets  will 
occasionally  be  seen  in  the  breast-fed  child.  If  the  mother  while  nursing 
suffers  with  malnutrition,  malaria,  chronic  cough,  or  with  any  organic 
lesion  which  devitalizes  the  body,  then  poor  breast-milk  deficient  in  its 
nutritive  elements  will  cause  the  body  to  be  underfed  and  finally  result 
in  rickets. 

Breast-fed  children  will  sometimes  show  rickets  when  they  have  been 
living  in  bad  apartments,  breathing  foul  air,  and  not  being  properly  cared 
for.  One  of  the  most  frequent  causes  of  rickets  is  ''prolonged"  nursing. 
In  the  section  on  "Breast-feeding"  I  have  already  pointed  out  the  neces- 
sity for  making  a  proper  chemical  examination  of  the  breast-milk  if  the 
infant  "shows  no  increase  in  weight."  We  know  that,  toward  the  end  of 
lactation,  not  only  do  the  proteids  diminish,  but  get  to  such  a  low  per- 
centage that,  unless  we  combine  hand-feeding  by  adding  the  raw  yolk  of 
egg,  steak  juice,  and  other  proteids,  like  the  cereals,  to  the  breast-feeding, 
the  child  will  be  underfed.  Underfeeding  is  certainly  a  contributing  factor 
to  the  causation  and  the  development  of  rickets. 


RACHITIS. 


845 


Fi".  95. 


Fig.  90. 


Fig.  97.  Fig.  93. 

inustiatiiic   Rachitic    Erosions    of   the    Permanent    Teetlu* 


'  I  am  indebted  to  Dr.  Hugo  Neumann,  Privat  dozent  iu  Berlin,  for  the  above 
illustrations. 


346  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

Symptoms. — One  of  the  first  symptoms  noted  is  constipation.  When 
there  are  evidences  of  gastric  disturbances,  unless  properly  treated,  chil- 
dren will  be  underfed  and  rickets  will  result.  Head  sweating,  especially  at 
night,  is  an  early  symptom  of  rickets.  Eolling  of  the  head  on  the  pil'ow, 
with  occipital  baldness,  frequently  precedes  the  development  of  rickets. 
Pallor  of  the  skin  and  profound  anaemia  frequently  precede  or  accompany 
the  development  of  rickets.  Rachitic  changes  affect  the  fontanel  and  the 
sutures,  as  well  as  the  whole  of  the  bones  of  the  cranium.  The  rhombic 
form  assumes  an  irregular  outline.  The  sutures,  especially  the  lamb- 
doidal  and  frontal,  are  distended. 

The  fontanel  remains  open  much  longer  than  in  normal  infants,  so 
that  not  infrequently  the  anterior  fontanel  can  still  be  felt  slightly  open 
as  late  as  the  third  or  fourth  year  of  life.  Although  the  usual  type  of 
rachitic  head  is  square,  not  infrequently  it  assumes  an  asymmetrical  form. 


Fig.  99. — Rachitic  Kibs.     Incurvation  of  the  ribs  at  the  osseous-cartilaginous 
junction  in  rickets.     One-half  natural  size.      (Langerhans. ) 

We  are  indebted  to  Elsiisser  for  a  description  of  one  of  the  most  valu- 
able symptoms  in  rickets,  namely,  "softening  of  the  cranial  bones,"  known 
as  ''craniotabes."  Small  areas  of  softened  bone  which  will  yield  on  the 
slightest  pressure  can  be  felt  in  the  region  of  the  lambdoidal  suture. 

-  Early  symptoms  of  rickets  also  are  tetanic  seizures,  muscular  spasms, 
and  laryngeal  spasms.  Dentition  is  delayed,  the  teeth  appearing  irregu- 
larly, and  in  older  children  they  are  carious.  Not  infrequently  we  find 
no  evidence  of  teeth  until  the  child  is  16  or  18  months  old.  Eachitic  symp- 
toms appear  later  in  the  thorax  than  in  the  head,  although  they  can  be 
plainly  made  out  during  the  first  six  months.  Beaded  ribs  are  especially 
prominent  in  advanced  cases.  There  is  a  marked  depression  of  the  thorax 
in  a  line  parallel  with  and  on  either  side  of  the  sternum.  This  line  cor- 
responds with  the  course  of  the  beads.  The  so-called  pigeon-breast  or 
funnel-breast  (pectus  carinatum)   is  frequently  observed  in  rickets. 

The  veins  of  the  scalp  are  usually  enlarged.  Spinal  rickets  is  espe- 
cially characteristic    The  posterior  curve  of  the  spine  is  commonly  known 


RACHITIS. 


847 


as  rachitic  kyphosis.     It  extends   from   the   middle-dorsal   to  the   sacral 
region. 


Fig.  100. — Case  of  Rickets  Showing  Enlarged  Spleen,  also  Pendulous 
Belly.      (Original.) 

This  kyphosis  has  been  found  in  more  than  one-half  of  my  cases.  The 
curve  can  be  lessened  or  it  will  disappear  when  the  child  is  placed  on  its 
back  and  extension  is  made  on  the  extremities.  The  more  important 
rachitic  deformities  are: — 

1.  Rachitic  kyphosis. 

2.  Eachitic  scoliosis. 

3.  Chicken  (or  pigeon)   chest. 

4.  The  rachitic  pelvis. 

5.  Cubitus  valgus  or  varus. 
Distortion  of  the  lower  extremities: — 

(a)  Genu  varum. 

(h)  Genu  valgum. 

(c)  Anterior  curvature  of  the  tibiae. 

(d)  General  distortions  of  the  lower  limbs. 


6. 


348 


DISORDERS  RESULTING  FROM  I.Ml'ROrEU  NUTRITION. 


Diastasis  of  the  Itecti  Muscles  in  Riclcets. — When  the  muscles  lose  their 
tone,  we  frequently  have  the  hony  changes  soon  afterward.  Diastasis  of  tlie 
recti  musfles  of  one-half  or  one  inch  can  sojnetinies  be  made  out.  To  pro- 
perly examine  a  child  for  this  condition  it  should  be  laid  on  its  back  with  the 
head  and  shoulders  elevated,  thus  the  recti  muscles  will  relax  and  a  pro- 
trusion of  the  abdominal  contents  in  the  median  line  can  be- noted. 

The  clavicle  is  affected  only  in  severe  cases.  Not  infrequently  there 
may  be  a  green-stick  fracture.  I  have  frequently  noted  the  exaggeration 
of  the  anterior  curve  at  the  inner  third  of  the  bone  which  is  described  by 
Holt.  There  are  various  pelvic  deformities  such  as  the  narrowing  of  the 
subpubic  arch.  There  is  also  a  contraction  of  the 
antero-posterior  diameter  of  the  pelvic  bones. 
For  further  details  I  will  refer  the  reader  to  Gar- 
rigues'  "System  of  Obstetrics.''  In  girls  the 
neglect  of  rickets  in  infancy  may  mean  serious 
trouble  in  womanhood  if  pregnancy  occur. 

Extremities. — It  is  not  difficult  to  note  de- 
formities in  the  humerus.  The  epiphyses,  as  in  all 
long  bones,  are  thickened  and  enlarged.  The 
thickening  of  the  epiphyses  in  the  radius  and  ulna 
is  readily  made  out.  The  shafts  of  these  bones 
describe  a  convexity  upon  their  extensor  surface. 
Green-stick  fractures  are  very  common  in  these 
bones.  The  ends  of  the  metacarpal  or  of  the 
phalanges  are  sometimes  enlarged. 

Tlie  Lower  Extremities. — The  outward  bend  of 
the  tibial  and  in  marked  cases  of  the  femoral 
produce  the  condition  known  as  bow-legs  (genu 
varum).  (Fig.  103.)  In  these  cases  when 
the  feet  are  put  together  the  knees  are  far 
apart.  The  opposite  condition  known  as  knock-knee  (genu  valgum) 
may  exist  The  inner  condyles  of  the  femur  are  hypertrophied,  so 
that  when  the  knees  are  put  together  the  feet  are  far  apart.  Knock-knees 
are  more  common  in  females.  The  ligaments  around  the  joints  are  relaxed 
and  weakened,  so  that  from  an  anatomical  standpoint  they  assist  in  pro- 
ducing this  deformity.  The  muscles  show  marked  evidences  of  this  disease. 
They  are  flabby,  soft,  and  small  with  poor  development.  This  accounts  for 
the  lateness  in  walking.  The  muscular  power  is  very  feeble,  and  not  infre- 
quently paralysis  Avill  be  suspected  when  really  we  are  dealing  with  ag- 
gravated rachitic  muscles. 

Malnutrition  is  plainly  made  out  on  studying  these  emaciated,  anaemic 
children  whose  bones  are  markedly  rachitic.  On  the  other  hand  we  fre- 
quently find  very  fat  children  with  extreme  pallor  showing  marked  rickets. 


Fig.  101. — Fivc-weeks- 
old  Fracture  of  the  Hum- 
erus, in  a  Rachitic  Child 
1  %  years  old.  ( Langer- 
hans. ) 


RACHITIS. 


349 


a  • 
6 


Fig.  102. — Rickets.  Lojigitiulinal  section  tlirough  tlie  ossification  junc- 
tion of  the  upper  diaphyseal  end  of  the  femur  of  a  one-year-old  child  suffer- 
ing from  rachitis  of  moderate  degree,  a,  Unaltered  hyaline  cartilage.  6. 
Cartilage  in  the  first  stage  of  proliferation,  c,  Zone  of  proliferated  cartil- 
age cell  columns,  d,  (^olumns  of  proliferated  hypertrophic  cells,  e,  vessels 
located  in  the  cartilage,  with  fibrous  marrow  tissue,  f,  Decalcified  cartilage 
tissue,  g.  Osteoid  tissue,  h,  Remains  of  cartilage  tissue  in  osteoid  tissue. 
i,  Trahecuhr  of  decalcified  osteoid  tissue.  /.-,  TraheculiB  of  osteoid  and  fully 
formed  calcified  bone  tissue.     I,  Fibro-cellular  marrow  tissue.      (Zieglcr.) 


350 


DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 


Therefore,  a  fat  infant  is  not  necessarily  a  liealthij  infant.  The  abdomen 
is  enlarged  and  usually  tympanitic  on  percussion.  It  is  commonly  known 
as  the  "pendulous  belly."  This  latter  symptom  I  met  with  in  fully  90 
per  cent,  of  my  cases  in  a  large  children's  service  extending  over  many 
thousand  cases.  I  have  rarely  failed  to  note  the  distended  belly  in  rickets. 
The  loss  of  tone  in  the  abdominal  muscles,  and  especially  in  the  muscular 


Fig.  103.— A  Severe 
Type  of  Rickets  With 
Enlargement  of  Both 
Condyles  of  the  Femur. 
There  is  also  enlargement 
of  the  upper  epiphyses  of 
the  tibia  and  fibula.  The 
illustration  also  .shows 
enlargement  of  the  epi- 
physes of  the  ankles.  An 
antero  posterior  curva- 
ture (giving  the  bow-leg 
appearance)  is  plainly 
seen.  Note  also  the  en- 
larged epiphyses  of  the 
radius  and  ulna.  Drawn 
fro  m  a  photogiaph. 
(Original.) 


walls  of  the  stomach  and  intestines,  is  one  of  the  prime  reasons  for  con- 
stij)ation.  Occasionally  the  reverse  may  be  true  and  diarrhoea  may  be 
noted.  There  is  frequently  marked  distention  of  the  stomach  and  colon. 
The  stools  are  hard  and  dry,  causing  a  chronic  catarrh  of  the  colon.  We 
frequently  find  at  the  end  of  the  stool  a  large  amount  of  glairy  mucus. 
The  pulse  and  temperature  are  normal.  Occasionally  a  bruit  can  be 
heard  over  the  anterior  fontanel.  It  has  no  special  significance.  There 
is  nothing  characteristic  in  the  urine  in  rickets.  The  blood  has  been 
studied  l)y  ]\Iorse,  who  concludes  that  anamiia  is  present  in  most  cases. 
Its  intensity  varies  with  the  intensity  of  the  rachitic  process.  Leucocytosis 
may  or  may  not  be  present.    An  enlarged  spleen  is  met  with  in  these  cases. 


RACHITIS.  351 

Convulsions  and  spasms  of  various  descriptions  occur  frequently  in 
rickets.  There  ;seems  to  be  a  predisposition  to  general  tetany,  and  to  laryn- 
geal spasm  (laryngismus  stridulus).  The  general  weakness  of  the  body 
is  also  seen  in  the  marked  tendeucy  to  irritation  in  the  nerve  centers. 
Most  diseases  in  rachitic  children  are  ushered  in  with  convulsions,  thus 
showing  the  extreme  sensitiveness  and  susceptibility  of  the  nerve  centers. 
An  overloaded  stomach  in  a  rachitic  child  under  1  year  of  age,  suffering 
with  high  fever,  is  usually  attended  with  hyperpyrexia  and  convulsions. 

Diagnosis. — This  is  usually  very  easy.  Head  sweating,  constipation, 
restlessness  at  night,  delayed  dentition  without  palpable  osseous  mani- 
festations usually  mean  rickets.  The  most  prominent  symptoms  are  beaded 
ribs,  enlargement  of  the  epiphyses  of  the  wrists  and  ankles,  kyphosis  of 
the  spine,  and  bow-legs. 

Differential  Diagnosis. — The  rachitic  head  is  sometimes  mistaken  for 
hydrocephalus.  The  electrical  reaction  will  decide  whether  or  no  we  are 
dealing  with  a  poliomyelitis,  or  if  the  case  is  a  pseudo-paralysis  with 
rickets.  We  must  differentiate  the  bony  enlargements  of  syphilis  from 
rickets  by  remembering  that  the  hony  changes  in  syphilis  affect  the  shaft 
of  the  hone  rather  than  the  extremities  as  previously  described.  An  im- 
portant point  to  remember  is  that  in  syphilis  there  may  be  necrosis.  This 
is  never  seen  in  rickets.  The  differential  diagnosis  will  best  be  made  by 
obtaining  a  complete  clinical  history  and  eliminating  all  doubtful  symp- 
toms. Scurvy  is  easily  differentiated  from  rickets  by  the"  spongy  condition 
of  the  gums,  by  the  tendency  to  haemorrhage,  and  usually  also  by  the 
presence  of  ecchymotic  spots.  The  diagnosis  of  rachitic  kyphosis  from 
spinal  tuberculosis  (Pott's  disease)  is  easily  made,  although  I  have  seen 
one  case  in  which  there  existed  a  rachitic  kyphosis  in  a  tuberculous  child. 

Prognosis  and  Course. — Rickets,  per  se,  is  rarely  fatal.  The  active 
symptoms  exist  al)0ut  one  or  two  years;  in  rare  instances  for  many  years. 
Permanent  damage  of  the  system  may  remain  throughout  life.  Spinal 
curvatures  and  thoracic  deformities  will  remain  for  muny  years. 

Rachitic  children  when  attacked  by  infectious  diseases  suffer  far 
more  and  the  prognosis  is  graver  than  it  would  be  otherwise.  The  abnormal 
condition  of  the  thorax  in  rachitic  children  must  always  be  taken  into 
consideration  in  a  child  suffering  with  pneumonia,  pleurisy,  or  other  pul- 
monary conditions,  in  estimating  the  outcome  of  the  disease. 

Treatment. — Prophylactic  Treatmeni:  The  preventative  treatment  of 
rickets  consists  in  giving  the  infant  healthy  surroundings,  ])lenty  of  fresh 
air,  and  by  all  means  human  milk  of  the  required  quality  and  quantity. 

Hygienic  Treatment. — When  rachitic  conditions  are  established  the 
first  tiling  to  do  is  to  insist  upon  removing  such  children  to  hoalthful  sur- 
roundings.    When  children  arc  housed  in   poorly   ventilated   lionics.   dark 


352  DISORDERS  RESULTING   FROM  IMPROPER  NUTRITION. 

rooms,  without  punsliine,  it  is  useless  to  give  inedieinc  until  the  nusani- 
tary  surrouudiugs  are  improved.  Successful  treatment  in  such  cases  de- 
mands plenty  of  sunshine,  open  windows,  night  and  day,  a  tub  bath  with 
a  handful  of  sea  salt  added  every  day.  After  the  bath  good  brisk  rubbing 
to  stimulate  the  circulation  is  very  necessary.  A  change  of  air  from  tlie 
city  to  the  country  is  desirable.  ^Yhen  we  are  prescribing  for  the  poor 
they  should  be  instructed  to  remain  in  tlie  park  as  much  as  possible.  The 
establishment  of  small  roof  gardens  on  the  tops  of  the  highest  dwelling  or 
tenement  houses  makes  a  cheerful  place  for  the  rachitic  children  to  play. 
Dietetic  Treatment. — Next  to  hygienic  methods  the  care  of  the  diet 
is  important.  If  a  nursing  infant  shows  rachitic  symptoms  the  chemical 
examination   of  the  breast  milk,  as   outlined    (see*  cha])ter   on   "Chemical 


Fig.  104. — Rickets,  Sliowing  Beaded  Ribs  and  an  Enlarged  Pendulous 
Belly.  Movith-bieatlier  due  to  adenoids.  Breast-fed  infant.  Always  lived 
in  tenement  house  district.     Mother  very  anaemic.      (Original.) 

Analysis  of  Breast  Milk"),  should  be  determined.  If  we  find  low  proteids 
the  nursing  mother  or  wet-nurse  should  be  given  more  meat,  eggs,  and 
cereals.  If,  however,  conditions  exist  which  prevent  proper  nursing,  tlie 
child  should-  be'  weaned.  A  properly  modified  cows'  milk  adapted  for  the 
age  and  development  (see  chapter  on  "Infant  Feeding")  should  l)e  sub- 
stituted. When  rickets  exist,  proteids  are  demanded.  I  insist  on  feeding 
such  children  with  cereals,  such  as  barley,  rice,  cream  of  wheat,  sago, 
farina,  etc.,  and  giving  them  plenty  of  fresh  vegetables,  such  as  spinach, 
asparagus,  peas,  and  beans.  Eggs,  white  meats,  and  fish  may  be  given  if 
children  are  old  enough.  Fresh  fruits  must  not  be  forgotten.  Butter  and 
cream  are  valuable  adjuncts  to  the  dietary. 

Medicinal  Treatment. — In  addition  to  the  importance  of  proper  feed- 
ing we  must  seek  to  establish  proper  metabolism.  All  the  emunctories 
must  be  carefully  watched.     Drug  treatment  should  be  directed  to  supply- 


IIACHITIS.  353 

ing  the  deficient  amount  of  lime  in  tlie  bones.  The  glycero-phosphate  of 
lime  which  has  been  used  by  me  for  several  years,  in  doses  of  1  to  5  grains, 
three  times  a  day,  is  very  useful.  Codliver-oil  or  morrholine,  to  which 
V200  grain  of  j)hosphorus  is  added,  has  served  me  very  well  in  some  in- 
stances. This  phosphorized  codliver-oil  must  be  freshly  prepa.red,  as  it 
deteriorates  on  standing.  Quite  a  discussion  as  to  the  value  of  phosphorus 
has  arisen  abroad  during  the  last  few  years.  Monti,  of  Vienna,  and  Bagin- 
sky,  of  Berlin,  and  Zweifel,  of  Leipzig,  deny  the  medicinal  virtue  of  phos- 
phorus in  rickets.  The  claims  of  Kassowitz,  of  Vienna,  the  originator  of 
this  treatment,  have  not  proven  successful  in  iny  hands.  Hundreds  of 
children  in  the  crowded  sections  of  the  city  have  been  put  on  the  phosphor 
treatment.     When  codliver-oil  was  added  to  the  phosphor,  good  results 


Fig.  105.— Rir-kets.    -  Note  Beaded  Ribs  on  Loft  Side  of  Thorax.      (Original.) 

were  noted,  not  otherwise;  so  that  I  believe  it  is  the  codliver-oil  rather  than 
the  phosphor  that  possesses  medicinal  virtues.  Fellows'  syrup  of  hypos- 
pistes,  arsenic,  iron,  and  strychnine  have  served  me  very  well,  especially 
wlien  atony  of  the  stomach  or  dyspeptic  conditions  existed.  The  careful 
regulation  of  the  bowels  and  good  action  on  the  part  of  the  kidneys  and 
skin  will  greatly  aid  in  modifying  rickets  when  established. 

Treatment  of  Deformities. — Kyphosis:  In  rachitic  kyphosis  a  Brad- 
ford frame  or  a  similar  aj)plianeo  is  indicated.  A  spinal  brace  will  some- 
times do  good.  Massage  with  good  friction  will  develo])  a  weakened  spine 
in  some  cases,  and  plaster  of  Paris  Jackets  may  be  serviceable.  Manual 
correction  of  the  deformity  will  aid  in  the  treatment. 

History  of  Rickets  in  Infancy. — A  Very  anaumic,  poorly  developed  girl.  Brouglit 
lip  in  a  tenement  house  in  the  thickly  crowded  portion  of  New  York  City.  Was 
l)rfast-fed  during  infancy,  fifteen  niontlis.  Had  sTimmer  coniijlaint.  Dentition  began 
at    eight   months,   walking   at   sixteen    months.       Very    briglit    mentally.      Is    very 


854  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

restless  at  night,  nervous  choreic  twitching  during  the  day.  No  mammnrj 
development,  no  evidence  of  menstruation. 

Father  and  mother  of  this  child  are  apparently  well,  though  dyspeptic.  No 
evidence  of  syphilis  or  tubercular  disease.  This  child  has  had  tonsillar  infections 
several  times  each  year;  had  diphtheria,  measles,  and  scarlet  fever.  Has  diarrhoea 
whenever  nervous  or  frightened. 

Since  instituting  gymnastic  exercises,  the  muscles  of  the  back  have  been 
greatly  strengthened,  although  the  spinal  deformity  has  not  been  lessened  or 
improved. 

The  main  treatment  consisted  in  fresh  air,  out-of-door  exercise,  diet  of  milk, 
cream,  butter,  fruits,  cereals,  and  meats.     Stop  school  and  uU  studies. 


Fig.   106.  Fig.   107. 

Fig.  106. — Rachitic  Kyphosis  (Spine).  Permanent  deformity.  Rachitic 
thorax  in  school  girl,  12  years  old,  showing  Harrison's  groove,  and  funnel- 
shaped  depression  of  sternum. 

Fig.  107. — Back  View  Same  Child,  Showing  Rachitic  Kyphosis.  This 
deformity  is  the  permanent  result  of  rickets  in  infancy.  It  is  to  be  differ- 
entiated from  Pott's  disease.  Note  also  the  curvature  of  the  spine. 
(Original.) 

Medication,  codliver-oil,  malt,  glycerophosphate  of  lime  and  soda,  raw  eggs, 
wine  in  moderation.  Cool  sponging  with  sea  salt.  Friction  of  body  after  gymnastic 
movements. 

Scoliosis  (Lateral  Curvature)  and  Lordosis  (Forward  Curvature  of  the 
spine) — The  management  of  tliese  conditions  is  similar  to  that  described  for 
kyphosis. 

Cubitus,  Varus,  and  Valgus. — These  deformities  disappear  as  a  rule 
without  special  treatment. 


RACHITIS.  355 

Bow-legs  (Genu  Varum). — This  common  rachitic  distortion  may  be 
coniienital  or  it  may  be  an  acquired  condition.  The  treatment  consists  in 
su]>i)ort  and  correction  by  braces. 

Whitman  believes  that  correction  by  osteotomy  or  osteoclasis  is  neces- 
sary when  children  are  over  5  years  of  age.  For  knock-knees  braces  are 
usually  necessary.  The  Thomas  knock-knee  brace  is  the  most  efficient.  In 
some  cases  osteotomy  of  the  femur  just  above  the  epiphyseal  line  is  indi- 
cated. 

Ante ro- posterior  how-leg  can  only  be  corrected  by  osteotomy. 

Genu  Recurvatum  (Back-l-nee). — Whitman  states  that  in  its  most 
extreme  form  it  is  of  congenital  origin,  and  is  usually  associated  with 
defective  development  of  the  anterior  thigh  muscles  and  of  the  patella. 
In  such  cases  the  knee  is  bent  directly  backward,  and  the  tibia  is  often  dis- 
placed forward  upon  the  femur.  In  the  milder  types  of  back-knee  there 
is  simply  an  abnormal  or  over-extension  caused  by  laxity  of  the  ligaments 
and  supporting  muscles.  This  form  is  usually  secondary.  It  is  often  seen 
in  cases  of  hip  disease  after  prolonged  mechanical  treatment.  It  may  l)e 
associated  with  congenital  talipes,  or  it  may  be  the  direct  result  of  paral- 
ysis of  the  muscles  of  the  legs,  or  even  of  general  weakness,  as  in  severe 
rachitis. 

The  following  are  the  principal  points  in  the  differential  diagnosis  of 
rickets  and  Pott's  disease: — 

Table  No.  50. 
I'iclrtfi.  Pntl's  Disease. 

l^pformity  not  angiil;iv.  Angular. 

Result  of  posture.  IJcsult  of  losiou. 

Evidences  of  rickets  elsewhere.  Absent. 

In  infancy.  Usually  later. 

In  middle  and  lower  part  of  the  spine.  In  any  part. 

The  body  may  be  bent  forward  with-  Forward  Hexion  causes  pain, 
out  discomfort. 

The  curve  is  lessened,  or  it  may  be  Never  disappears, 
obliterated  when  tlie  trunk  is  ex- 
tended. 

Surgical  Treatment. — It  is  always  safe  advice  to  consult  a  surgeon  or 
orthopa?dist  concerning  deformities  in  early  life.  Very  many  rachitic  de- 
foi'Miitics  due  to  softened  diapheses  can  be  corrected  or  modified  as  de- 
scril)('d  in  tlic  treatment  previously  given.  When  a  brace  appears  unsatis- 
factory tlien  surgery  may  yield  excellent  service,  but  surgery  must  be  used 
in  conjunction  with  proper  nutrition  and  restorative  treatment  to  secure 
permanent  bcnelit. 


356  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

Athrepsia  Infantum    (Infantile  Atrophy,  Marasmus,  or 
Wasting  Disease). 

This  condition  is  met  with  as  a  result  of  malassimilation  of  food.  It 
is  really  a  deficient  metabolism,  and  results  in  a  gradual  decline.  It  is 
important  to  note  that  constitutional  disorders,  such  as  tuberculosis  or 
syphilis,  are  not  the  causative  factors. 

When  the  digestive  function  is  impaired  and  food  is  not  assimilated, 
then  wasting  follows.  An  inquiry  into  the  cause  leading  to  this  disturb- 
ance is  naturally  of  interest,  as  thereby  we  can  frequently  find  therapeutic 
measures  necessary  to  modify  and  frequently  to  cure  this  disease. 

Etiology. — What  are  the  causes? 

1.  Improper  food,  (a)  Over-feeding;  too  rich  food,  (h)  Under- 
feeding;  lack  of  nutriment. 

2.  Bad  hygiene. 

3.  Too  frequent  feeding;   improper  quantity. 

4.  Congenital  defects,     (a)  Harelip,     (b)  Adenoids. 

5.  Inherited  diseases. 

6.  Improper  development.  Premature  birth  and  its  consequent  sub- 
normal digestive  powers. 

7.  Sequelae  to  acute  infections;  subsequent  paralysis  preventing 
proper  digestive  functions. 

Henoch  does  not  like  the  term  "athrepsia"  introduced  by  Parrott,  but 
prefers  "atrophy."  The  first  symptom  that  this  author  noticed  is  that  the 
child's  weight  does  not  increase;  hence  he  emphasizes  the  importance  of 
frequently  weighing  children.  He  regards  the  weight  taken  once  a  week 
as  sufficient,  so  that  it  can  be  the  determining  factor  as  to  the  progress  made 
by  an  infant.  Henoch  says  that  at  the  end  of  the  first  month  the  weight 
is  increased  one-third,  at  the  end  of  the  fifth  month  it  is  double,  and  at 
the  end  of  the  twelfth  month  it  is  three  times  the  weight  at  birth.  Wean- 
ing, dentition,  and  all  other  pathological  conditions  interfere  with  a  proper 
increase  in  weight. 

By  far  the  greatest  number  of  cases  of  athrepsia  are  found  in  bottle- 
fed  children.  There  are,  however,  a  great  many  cases  to  be  seen  among 
breast-fed  children.  We  can  then  be  positive  that  the  breast-milk  is  lack- 
ing in  some  of  its  chemical  constituents,  and  frequently  we  find  that  it  is 
the  proteids  that  are  deficient  in  quantity.  If,  therefore,  we  meet  with  a 
case  of  athrepsia  in  a  breast-fed  child,  the  thing  to  do  is  to  have  a  chemical 
examination  made  of  the  breast-milk.  If  it  is  found  deficient  in  quality, 
then  we  must  withdraw  it  and  substitute  bottle-feeding. 

A  great  many  children  will  be  found  to  thrive  at  once  after  having 
been  removed  from  the  breast  and  changed  to  some  artificial  mode  of  feed- 
ing, whereas  the  reverse  is  also  true.    If  we  wish  to  discard  the  mother's 


ATHREPSIA  INFANTUM.  357 

milk^  for  some  positive  reason,  then  it  is  advisable  to  secure  a  wet-nurse 
having  a  child  as  near  as  possible  to  the  age  of  the  one  she  is  about  to  suckle. 
The  hereditary  history  of  a  nurse  is  of  great  importance,  as  is  also  the 
(juality  and  quantity  of  her  milk,  which  should  be  thoroughly  examined 
before  she  is  given  this  foster-child.     (Eead  chapter  on  "'Wet-nurse.") 

Pathology. — There  are  no  distinct  lesions  which  can  be  called  specific 
in  marasmus.  In  some  there  may  be  a  fatty  liver  associated  with  a  gen- 
eral tuberculosis.  The  brain  is  commonly  anajmic  with  dark  fluid  blood 
in  the  sinuses,  marantic  thrombi  being  rare.  In  many  young  infants  areas 
of  atelectasis  are  found  in  the  lower  lobes.  The  heart,  spleen,  and  kidneys 
arc  pale,  but  otherwise  normal.  The  solitary  follicles  of  the  colon,  the 
small  intestines,  and  some  times  Peyer's  patches  are  slightly  enlarged,  the 
mucous  membrane  in  other  respects  being  normal.  The  mesenteric  glands 
are  often  slightly  enlarged  (Holt).  The  true  pathology  seems  to  be  a 
failure  to  assimilate  food  in  infants  with  improper  hygiene,  and  as  a  result 
j)rogressive  emaciation  takes  place. 

Symptoms. — When  infants  suffer  with  vomiting  or  diarrhoea,  and  this 
condition  is  allowed  to  become  chronic,  then  colic  and  flatulence,  associated 
with  constipation,  supervene,  and  the  result  is  a  gastro-intestinal  catarrh. 
Neglect  of  this  condition  means  the  development  of  the  condition  known 
as  athrepsia.  The  infant  does  not  thrive,  commences  to  waste,  and  unless 
we  realize  the  eondit'on  and  give  the  baby  proper  treatment,  such  a  child 
will  die  from  exhaustion  and  from  inanition.  When  these  cases  linger  for 
months  they  develop  rachitis.  Eecovery  without  treatment  is  impossible. 
Parrott  was  the  first  to  define  this  disease  and  classify  it  into  three 
stages : — 

1.  The  infant  suffers  from  a  simple  diarrhrea  or  looseness  of  the  bow- 
els. The  stools,  instead  of  being  bright  yellow  and  homogeneous,  are  liquid, 
curdy,  often  of  a  greenish  color,  and  contain  an  excessive  quantity  of  mu- 
cus. The  abdomen  is  distended  with  gas  and  remains  constantly  in  this 
condition.  The  tongue  is  coated  and  the  patches  of  a  stonuititis  appear  in 
the  mouth.  The  infant  is  restless,  constantly  whining,  and  will  not  sleep 
at  night.  The  milk,  being  retained,  curdles;  the  tissues  become  flabby, 
and  wasting  commences. 

2.  The  symptoms  are  intensified  and  the  characteristic  wasting  be- 
comes manifest.  The  stools,  for  the  most  part,  are  loose  and  frequent,  and 
consist  of  undigested  food.  The  stools  are  frequently  pale  and  putty-like, 
with  a  peculiar  odor.  At  other  times  they  are  dark  brown  from  the  pres- 
ence of  altered  bile.  The  infant  is  most  voracious,  liquid  food  does  not 
seem  to  satisfy  it,  and  by  the  mistaken  kindness  of  its  friends  it  is  fed  with 
some  thick  food  like  soft  bread,  a  diet  which  has  the  great  advantage  in 
their  eyes  of  keeping  it  quiet  for  a  longer  time  than  liquid  food  or  diluted 
milk.    At  times  it  can  hardly  be  made  to  sleep,  or  only  dozes  for  a  short 


358  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

time,  unless  under  the  influence  of  a  soothing  syrup  given  by  its  nurse. 
The  mouth  becomes  the  seat  of  a  parasitic  stomatitis;  the  skin  is  harsh 
and  dry;  small  boils  or  a  lichenous  rash  make  their  appearance.  The  but- 
tocks and  genitals  are  raw  and  excoriated.  The  temperature  is  below  nor- 
mal; the  feet  and  hands  are  congested;  the  face  has  a  pallid,  earthy  tint, 
and  a  sickly  lactic-acid  smell  is  given  out  from  the  body,  especially  the 
abdomen.  The  wasting  is  extreme,  the  face  being  shriveled,  the  skin 
wrinkled  and  hanging  in  folds  about  the  arms  and  thighs. 


Fig.  108. — Athrepsia  Infantum.  The  loss  of  fat  causes  the  skin  to 
hang  in  loose  folds.  Note  the  left  forearm  and  both  legs.  The  forehead 
is  wrinkled.  The  hand  in  the  mouth  is  a  characteristic  symptom  of 
starvation.      (Original.) 

3.  The  third  stage  brings  the  child  into  a  moribund  state.  It  is  too 
feeble  to  cry,  becomes  heavy  and  drowsy,  taking  little  notice  of  anything. 
Death  then  ensues,  probably  preceded  by  a  muscular  twitching,  strabismus, 
or  general  convulsions. 

Prognosis  and  Course. — The  course  of  this  condition  depends  on  the 
amount  of  nutrition  that  can  be  assimilated.  The  worst  forms  of  marasmic 
children  will  frequently  gain  in  weight  when  proper  food  is  given.  If  the 
appetite  is  poor  a  decided  change  of  air,  from  the  city  to  the  country,  or 
vice  versa,  will  strengthen  the  infant  and  restore  the  appetite.  Many  a 
child's  life  has  been  saved  by  a  trip  to  the  seashore  or  a  sea  voyage.    The 


ATHREPSIA  INFANTUI^L  359 

outcome  of  the  case  depends  on  judicious  feeding,  a  change  of  air,  and 
proper  hygienic  management. 

The  treatment  of  this  disease  is  one  that  resolves  itself  into  removing 
the  cause,  and  if  bad  hygienic  surroundings — as  impure  air,  crowded  apart- 
ments, and  improper  diet — are  the  cause,  then  these  must  be  remedied  at 
once.  Medication  amounts  to  nothing  in  the  treatment  of  this  disease. 
With  hand-fed  or  bottle-fed  children  we  can  easily  regulate  the  condition 
of  their  bowels,  and  also  easily  regulate  the  quantity  and  the  quality  of 
food  given  them.  The  blandest  and  least  irritating  food  must  be  selected, 
while  frequent  weighing  of  the  infant  should  be  resorted  to  in  order  to 
ascertain  the  progress  that  is  being  made. 


Fig.  ion. — Athrepsia  Infantum.  The  emaciation  is  seen  on  the  neck, 
right  arm,  the  thighs,  and  legs.  The  tendons  on  the  right  foot  are  plainly 
seen.      (Original.) 

In  some  children  milk  or  milk  foods  are  badly  assimilated  and  gastric 
symptoms  follow;  it  may  be  wise  to  discontinue  milk  for  several  weeks. 
By  this  means  we  give  the  stomach  absolute  rest  and  can  order  food  that 
is  more  easily  assimilated  until  such  time  when  milk  may  again  be  tole- 
rated. My  plan  has  been  to  order  whey  made  by  straining  the  curd  out  of 
milk  (see  "Dietary")  ;  6  to  8  ounces  of  whey  may  be  given,  to  which  the 
yolk  of  a  raw  egg  may  be  added.  Concentrated  chicken  soup  thickened 
with  sago,  farina,  or  barley  may  be  given  in  quantities  of  4  to  6  ounces, 
alternating  with  whey.  A  child  of  1  year  may  be  fed  every  three  hours  if 
marked  emaciation  exists.  The  value  of  vegetable  soups,  such  as  pea,  bean, 
or  lentil  soup,  strained,  must  not  be  forgotten.  Roasted  flour  made  as  a 
flour  ball  (sec  page  77)  may  be  added  in  the  proportion  of  a  tcaspoonful 
to  4  or  G  ounces  of  soup.  An  emulsion  of  sweet  almonds  may  be  tried  as  a 
vahiable  and  nutritious  vegetable  proteid.  Steak  juice,  roast  beef  juice,  or 
beef  blood  is  indicated  in  doses  of  2  to  G  ounces  once  or  twice  a  day. 


360  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

Where  there  is  much  diarrhoea  milk  must  be  used  sparingly  or  alto- 
gether omitted  for  a  while,  as  the  hard  curds  formed  in  the  stomach  are 
beyond  the  feeble  digestive  powers  of  the  weakened  stomach  and  intestines. 
Small  quantities  of  whey  and  barley  water,  yolk  of  egg  and  barley  water, 
or  the  juice  of  a  rare  chop  or  steak  may  be  given  at  short  intervals  during 
the  day  and  night. 

As  soon  as  the  child  improves  in  respect  to  the  diarrhoea,  milk  in  some 
form  may  be  allowed.  Peptonized  milk  is  often  of  much  value  in  these 
diseases  when  made  by  mixing  3  ounces  of  cold  milk,  adding  2  tablespoon- 
fuls  of  cream,  with  half  of  a  peptonizing  powder.  In  addition  to  the  above 
the  white  of  a  raw  egg  or  the  yolk  of  an  egg  may  be  well  beaten  up  with 
water  and  given  in  teaspoonful  doses.  When  the  stomach  rejects  all  food, 
rectal  feeding  may  be  resorted  to  (see  chapter  on  "Rectal  Feeding").  High 
saline  injections  will  be  urgently  called  for  in  this  wasting  condition.  They 
may  be  repeated,  if  beneficial,  two  or  three  times  a  day.  Several  pints  of 
saline  solution  may  be  slowly  injected. 

Restorative  treatment  will  consist  in  giving  small  doses  of  codliver-oil, 
iron,  malt,  and  arsenic  if  the  stomach  will  tolerate  the  same.  The  inunc- 
tion of  warm  codliver-oil  over  the  entire  body  every  morning,  is  frequently 
of  service.  The  outcome  of  the  case  usually  depends  on  perseverance  and 
judicious  feeding. 

Marasmic  and  atrophic  children  do  well  on  Keller's  malt  soup.^  This 
preparation  has  been  used  by  me  with  very  good  result.  When  it  was  diffi- 
cult to  prepare  this  food  the  following  formula  served  me  equally  well: — 

Raw  cows'  milk 4  ounces 

Maltine,  plain 1  teaspoonful 

Bicarb,  of  potassium   20  grains 

Eskay's  food 2  teaspoonf uls 

Rice  water   ; 4  ounces 

Mix  the  above  and  heat  slowly  for  three  minutes  until  it  boils.  Allow 
it  to  boil  one  minute.  Feed  every  three  or  four  hours.  If  the  food  agrees 
well  add  one-half  ounce  of  milk  more  every  four  days.  The  Eskay's  food 
should  also  be  increased  until  three  teaspoonf  uls  are  given  with  each  feeding. 
If  the  child  vomits  reduce  the  quantity  of  maltine  to  one-half  teaspoon. 


'Formula  of  Keller's  malt  soup.     See  page  170. 


PART  V. 

DISEASES  OF  THE  HEART,  LIVER,  SPLEEN,  PANCREAS, 
PERITONEUM,  AND  GENITO-URINARY  TRACT. 


CHAPTEE  I. 
INTRODUCTORY.  _ 

The  Heart  and  Fcetal  Circulation. 

The  circulation  of  the  blood  during  the  whole  foetal  period  of  ante- 
natal life  is  the  same.  From  the  third  to  the  tenth  month  the  circulation 
is  known  as  "placental/'  and  during  the  intervening  months  it  undergoes 
no  marked  modifications. 

According  to  Ballantyne^  during  the  neo-fcetal  period,  it  is  true  the 
circulation  is  that  of  the  chorion;  but  by  the  end  of  it  there  has  been  a 
specialization  of  the  circulatory  function,  and  the  blood,  instead  of  being 
sent  to  the  villi  over  a  wide  expanse  of  chorionic  surface,  is  now  directed 
solely  to  those  found  over  one  part  of  it,  that,  namely,  which  is  in  contact 
with  the  decidua  serotina,  the  site  of  the  developing  placenta.  From  the 
end  of  the  neo-fcetal  period  onward  to  the  moment  of  birth,  there  is  the 
circulation  of  the  placenta. 

The  essential  peculiarity  of  the  placental  circulation  is  the  sending  of 
the  fcetal  blood  out  of  the  fcetal  body  to  a  specially  prepared  and  extra- 
corporeal organ  (the  placenta)  for  purposes  of  oxygenation  and  other  less 
understood  chemical  changes.  This  entails  simply  the  presence  of  an 
efferent  vessel  (or  vessels)  to  carry  the  blood  to  the  extra-corporeal  organ 
and  of  an  afferent  vessel  to  bring  it  back  again. 

Changes  at  Birth. — When  the  umbilical  cord  is  ligated  there  is  an 
interruption  of  the  circulation  through  the  umbilical  vein  and  arteries,  so 
that  in  about  ten  days  after  birth  the  circulation  loses  its  foetal  type  and 
assumes  extra-uterine  conditions. 

The  following  physiological  changes  occur: — 

(a)  The  conversion  of  the  ductus  arteriosus. 

(b)  The  ductus  venosus  into  fibrous  cords. 

(c)  The  closure  of  the  foramen  ovale. 

(d)  Changes  in  the  umbilical  veins  and  umbilical  arteries.  The  first 
forming  the  round  ligament  of  the  liver,  the  second  the  true  anterior  liga- 
ment of  the  bladder  and  the  superior  vesical  arteries. 


'  For  those  interested  I  would  advise  reading  Ballantyne's  book  on  ante-natal 
pathology  and  hygiene. 

(361) 


3G2 


THE  HEART  AND  FOETAL  CIRCULATION. 


For  some  weeks  before  birth  the  circulation  through  the  foramen  ovale 

is  slight,  it  being  gradually  obstructed  by  the  growth  of  a  septum  which 
nearly  fills  the  space  at  birth.  After  the  first  week  of  extra-uterine  life, 
very  little  if  any  blood  passes  through  it,  although  complete  closure  of  the 
foramen  often  does  not  take  place  until  the  middle  of  the  first  year.  In 
one-fourth  of  the  autopsies  Holt  made  upon  infants  under  six  months  of 
age,  minute  openings  at  the  margin  of  the  foramen  ovale  were  found.  They 
were  usually  oblique,  and  closed  by  the  valvular  curtain  so  as  to  effectually 
obstruct  the  current  of  blood.  The  ductus  arteriosus  is  first  closed  by  a 
clot,  which  becomes  organized  and  blends  with  the  products  of  a  proliferat- 


Fig.  110. 


F  g.  111. 


Fig.  112. 


Fig.  110. — Note  the  Position  of  the  Apex  Beat  in  a  Very  Young  Infant; 
during  the  first  year  it  is  very  high,  between  the  fourth  and  fifth  intercostal 
spaces.     It  is  most  often  in  the  fourth. 

Fig.  111.— The  Apex  Beat  in  a  Child  About  6  Years  Old.  It  is  lower 
than  in  an  infant.    Usually  found  at  the  fifth  intercostal  space. 

Fig.  112. — The  Apex  Beat  in  a  Child  About  12  Years  of  Age  is  found 
between  the  fifth  and  sixth  intercostal  space. 

The  heavy  black  lines  denote  the  area  of  relative  dullness.  The  small 
shaded  areas  denote  the  area  of  absolute  dullness.     (After  Unger. ) 

ing  arteritis.     It  is  rarely  found  open  after  the  tenth  day,  and  by  the 
twentieth  it  is  almost  invariably  obliterated. 


The  Heart.* 

Size  of  the  Heart. — The  relative  size  of  the  heart  is  greater  in  children 
than  in  later  life.     It  is  smallest  about  the  seventh  year. 

Table  No.  57.— Weight  of  the  Heart  (Boyd). 
Age.  Grams. 

At  birth  20.6 

One  and  one-half  years   44.5 

Three  years 60.2 

Five  and  one-half  years 72.8 

Ten  and  one-half  years  122.6 

Seventeen  years 233.7 

*  Heart  murmurs  are  described  on  page  3G6. 


THE  HEART.  353 

The  anatomical  differences  in  the  child  are: — 

(a)  A  more  horizontal  position  of  the  heart  than  in  the  adult. 

(b)  The  diaphragm  being  liigher,  the  heart  is  higher  in  the  thorax. 

(c)  The  ribs  in  a  child  are  more  horizontal  than  in  the  adult. 

(d)  The  liver  in  young  children  is  larger  than  in  adults,  and  as  the 
heart  is  in  close  contact  with  the  liver  the  area  of  cardiac  dullness  merges 
into  that  of  the  liver  dullness  below. 

Tension. — The  degree  of  contraction  of  the  vascular  muscles  deter- 
mines the  size  of  the  artery  and  (to  a  great  extent)  tlie  tension  of  the 
l)lood  within  it.  But  if  the  heart  is  acting  feebly  there  may  be  so  little 
blood  in  the  arteries  that  even  when  tightly  contracted  they  do  not  subject 
the  blood  within  tliem  to  any  considerable  degree  of  tension.  "To  produce 
high  tension,  then,  we  need  two  factors:  a  certain  degree  of  power  in  the 
hcart-nniscles,  and  contracted  arteries.  To  produce  low  tension  we  need 
only  relaxation  of  the  arteries,  and  the  heart  nurg  be  either  strong  or  weak. 

"The  pulse  of  loir  tension  collapses  between  beats,  so  that  the  artery  is 
less  palpable  than  usual  or  cannot  be  felt  at  all.  Normally,  the  artery  can 
just  be  made  out  between  beats,  and  any  considerable  lowering  of  arterial 
tension  makes  it  altogether  impalpable  except  during  the  period  of  the 
primary  wave  and  of  the  dicrotic  wave,  which  is  often  very  well  marked 
in  pulses  of  low  tension."    . 

"The  pulse  of  liigh  tension  is  perceptible  between  beats  as  a  distinct  cord 
irjiicji  ran  he  rolled  hetireen  tJie  fingers,  like  one  of  the  tendons  of  the 
wrist.  It  is  also  difficult  to  compress  in  most  cases,  but  this  may  depend 
rather  on  the  heart's  power  than  on  the  degree  of  vascular  tension.  The 
juilse  wave  is  usually  of  moderate  height  or  low,  and  falls  away  slowly  with 
little  or  no  dicrotic  wave. 

Fig.    113. — Irregular    Pulse,    Low  Tension,    from    a    Case   of    Mitral 
Regurgitation.      (Original.) 

Mode  of  Examination  of  the  Heart. — 1'he  car  should  be  used,  rather 
than  an  instrument  in  listening  to  the  heart  sounds  in  struggling  children. 
In  children  with  eruptive  fevers  it  is  safer  to  use  a  phenendoseope.  For 
this  purpose  the  Bowles  phenendoseope  (Fig.  114)  is  highly  recom- 
mended, as  it  has  a  flat  attachment  which  can  conveniently  be  placed  in 
the  axilla  or  to  the  posterior  portion  of  the  lung  without  raising  the  child 
from  the  bed.  These  advantages  are  important  inasmuch  as  we  frequently 
can  examine  the  child  while  asleep. 


364  THE  HEART  AND  FCETAL  CIRCULATION. 

The  following  aphorisms  are  drawn  from  Crantlall: 

1.  The  apex  lies  higher  in  the  chest  and  further  to  the  left  than  in 
the  adult. 


Fig.  114. — N.atural  Size  of  Bowle.s  Stethoscope  for  Examining  Children. 

2.  The  apex  beat  is  hard  to  detect  in  the  infant.  In  the  child  palpa- 
tion shows  this  easier  than  in  the  adult. 

3.  The  area  of  dullness  is  comparatively  large.  (There  are  three 
stages  in  infancy  and  childhood  during  which  differences  arc  noted  in  rela- 
tive and  absolute  dullness.)     (See  Figs.  110,  111,  and  113.) 


Fig.    115. — A  Convenient   Stethoscope  for  Children.     Made  by  Gr.   Tiemann 
&  Co.  and  by  George  Ermold,  New  York  City. 

4.  Murmurs  are  heard  over  comparatively  large  areas.  A  study  of 
differences  in  the  quality  of  the  sounds  and  points  of  greatest  intensity  will 
help  us  here. 

5.  The  rate  may  be  increased  and  the  rhythm  altered  by  slight  causes. 
G.  In  rachitic  children  and  in  those  affected  by  empyema  or  pleural 

effusions  and  adhesions  the  apex  may  appear  in  an  abnormal  position. 

7.  Prominence  of  the  precordia  is  sometimes  marked.  Normally  the 
loudest  sound  is  the  first  sound  at  the  apex;  the  weakest  sound  is  the 
second  sound  at  the  aortic  cartilage.     This  accords  with  my  experience, 


THE  HEART, 


365 


though  it  does  not  seem  to  be  generally  recognized  that  the  pulmonic  second 
sound  is  in  early  life  stronger  than  the  aortic  sound. 


Table  No.  58. — Classification  of  Cardiac  Diseases. 


Time  of 
Occurrence. 


Nature  of  the  Affection. 


Clinical  Di^sease. 


Intra-nterine 

existence 

or  very 

early  infancy. 


Extra -uterine 

existence 

(infancy  or 

childhood). 


Developmental 

or 
Inflammatory. 

Various  motor  or  sensory 
phenomena  unaccom- 
panied by  sensible 
changes  of  structure. 


Organic, 


Mechanical. 


,  Inflammatory. 


Miscellaneous. 


Various  congenital  affections. 


Functional  diseases  of  the  heart. 


(Dilatation,       "j  Alone   or  as  accom- 
>    paniraent     of      in- 
Hypertrophy,  J     flam  matory  change. 

{Pericarditis,  acute  or  chronic. 
Endocarditis,  acute  or  chronic. 
Myocarditis,  acute  or  chronic. 

{Eflusions  (non-inflammatory). 
Granulomata. 
Neoplasms. 


CHAPTER  II, 
DISEASES  OF  THE  HEART. 

Eeflex  Symptoms  of  the  Heart. 

Tachycardia. — Severe  palpitation  of  the  heart  (tachycardia)  fre- 
quently results  from  excitement  or  fright  in  children.  The  heart  on  aus- 
cultation will  be  found  normal,  and  the  only  symptom  noticeable  will  be 
an  exaggerated  pulse-rate  with  an  increase  of  twenty  to  forty  beats  per 
minute.  It  is  usually  a  neurotic  manifestation.  As  a  rule  the  prognosis 
is  good.    The  treatment  consists  in  removing  the  cause  if  possible. 

Bradycardia. — A  slowness  of  the  heart's  action  and  a  slow  pulse-rate 
is  occasionally  met  with  in  children.  It  may  occur  in  health,  although  very 
rarely  without- pathological  significance.  I  have  usually  seen  bradycardia  in 
septic  cases  of  diphtheria  at  my  service  in  the  Willard  Parker  Hospital,  and 
in  the  septic  type  of  scarlet  fever  at  the  Riverside  Hospital.  When  brady- 
cardia is  seen  during  the  course  of  acute  infectious  diseases  it  should  be 
regarded  as  a  very  serious  symptom  (see  chapter  on  ''Diphtheria"). 

Points  to  be  Noted  in  the  Diagnosis  of  Diseases  of  the  Heart, 

Heart  Sounds  and  Murmurs. 

First  Sound, — In  infectious  fevers  there  is  an  increase  in  the  length 
and  intensity  of  the  first  sound  heard  at  the  apex. 

In  continued  fevers  causing  degeneration  of  the  heart  muscles  there 
is  a  shortening  and  weakening  of  the  first  sound  heard  at  the  apex. 

In  exhaustive  heart  strain  seen  in  myocarditis  the  first  sound  is  feeble 
and  merges  into  the  second  sound.  This  condition  is  met  with  in  diph- 
theria, scarlet  fever,  and  typhoid,  although  any  disorder  of  the  body  which 
devitalizes  may  cause  it. 

Fatty  heart,  emphyf^ema  or  pericardial  effusion  may  give  a  feeble  mitral 
first  sound. 

Pulsus  Paradoxus. — The  licart-heats  during  inspiration  are  more  fre- 
(juent  hut  less  full  tlian  during  expiration.  This  condition  may  be  observed 
in  healthy  children  during  sleep. 

An  irregular  heart's  action  may  occur  during  sleep  in  healthy  children. 
The  heart's  action  is  frequently  influenced  by  inspiration  and  expiration. 

Systolic  Murmurs. — There  are  two  murmurs  possible  for  each  orifice, 
or  eight  in  all.  Of  these,  four,  namely,  mitral  systolic,  mitral  presystolic, 
(366) 


I 


MtmMURS.  367 

aortic  systolic,  and  aortic  diastolic,  are  most  likely  to  occur,  with  a  fre- 
quency about  in  the  order  of  their  enumeration.  The  necessary  changes 
being  made,  a  like  distribution  applies  to  the  right  side;  although  a  pul- 
monary lesion  is  almost  unknown,  except  as  a  congenital  affection,  while 
disease  of  the  tricuspid  valve  is  less  rare. 

Every  murmur  is  determined  by  the  time  of  its  occurrence,  the  direc- 
tion which  it  takes,  and  the  location  of  its  greatest  intensity.  The  blood 
is  driven  from  the  left  ventricle,  during  systole,  through  the  aortic  orifice; 
and,  meanwhile,  all  communication  with  the  auricle  of  this  side  is  cut  off 
by  a  closure  of  the  mitral  valve.  But  should  the  current  encounter  an 
obstacle  at  the  aortic  opening  in  its  onward  course,  it  would  be  thrown  into 
confusion  in  the  aorta,  from  which  a  murmur  would  arise  and  be  carried 
upward.  Hence  this  bruit  is  loudest  at  the  aortic  area,  systolic  in  rhythm, 
and  extends  in  the  direction  of  the  carotids. 

Should  the  mitral  valve  fail  to  close  at  tins  time  the  blood  would 
escape  into  the  left  auricle,  as  well  as  run  through  the  proper  channel,  and 
be  set  in  vibration  by  the  impeding  flaps  at  the  mitral  orifice.  Here  the 
bruit  generated  by  this  disturbance  is  borne  with  the  reflux  into  the  auricle, 
and  thence  to  the  back,  and  also  by  conduction  through  the  apex  to  the 
front.  Moreover,  it  is  loudest  in  front  and  at  the  apex,  because  the  heart 
is  nearer  the  anterior  than  the  posterior  surface  of  the  chest.  Therefore, 
this  murmur  is  most  intense  at  tlie  mitral  area,  systolic  in  rhythm,  com- 
monly diffused  to  the  left,  and  often  audible  near  the  inferior  angle  of  the 
left  scapula. 

In  a  similar  manner  during  systole,  the  blood  is  being  propelled  by 
the  right  ventricle  through  the  pulmonary  aperture,  and  likewise  the  tri- 
cuspid valve  is  closed  or  very  nearly  so.  Thus  supposing  that  an  obstruc- 
tion were  to  occur  at  the  pulmonary  orifice,  there  would  be  a  systolic  mur- 
mur, with  point  of  maximum  intensity  in  the  pulmonary  area  and  extension 
upward  to  the  left,  but  not  into  the  carotids. 

In  the  event  of  tricuspid  insufficiency,  part  of  the  blood  would  flow 
back  into  the  right  auricle,  and  give  rise  to  a  systolic  bruit,  best  heard  in  the 
tricuspid  area,  and  spreading  upward  to  the  right. 

Anaemic  Murmurs. — An  anaemic  murmur  is  always  systolic  in  rhythm, 
loudest  at  the  base  of  the  heart,  and  often  as  audible  in  the  aortic  as  the 
pulmonary  area.  With  anaemia  pure  and  simple  there  should  be  no  cardiac 
hypertrophy. 

Diastolic  Murmurs. — In  diastole  the  aortic  and  pulmonary  valves  are 
closed,  and  the  auriculo-vcntricular  valves  open,  while  blood  is  flowing  from 
the  auricles  to  the  ventricles.  The  vermicular  contraction,  styled  cardiac 
systole,  which  was  initiated  in  the  veins  and  taken  up  by  the  auricles,  has 
gone  through  the  ventricles  and  reached  the  large  arteries,  wherein  the  recoil 
of  the  current  finds  a  point  of  support  at  the  closed  semilunar  cusps. 


368  DISEA8KS  OK  'II  IK   IIKAHT. 

If  tlie  function  of  one  or  more  of  these  cusps  in  tlie  aortic  valvo  be 
clestroyed,  cacli  contraction  of  the  artery  will  drive  a  portion  of  its  contents 
back  into  the  left  ventricle;  and  the  vil:)rations  generated  in  this  return 
stream  against  the  disorganized  valve  will  cause  a  bruit  that  is  aortic  in 
origin  and  diastolic  in  rhythm. 

Though  this  murmur  of  insufficiency  is  conveyed  along  the  arteries  a 
varying  distance  in  the  efflux,  its  nuiin  direction  is  backward  witli  the  reflux  ; 
not  so  much  in  the  line  of  the  ventricle  as  down  the  sternum,  owing  to  the 
close  proximity  of  this  bone  to  the  aortic  valves,  and  its  superiority  over 
the  heart  as  a  conducting  medium  of  sound.  TJie  point  of  ma.vinnini  in- 
tensity of  this  bruit  is  more  often  at  the  lower  end  of  the  sternuni  tlian  in^ 
the  second  intercosted  space.  Granting  that  tlie  same  thing  could  happen 
to  the  pulmonary  valves,  a  diastolic  niiinniir  iroiild  he  audihJe  in  the  pnl- 
■nionanj  area,  hut  witJi  an  extension  downivard  only. 

An  aortic  systolic  murmur  is  loudest  in  the  second  right  iniercoslal 
space  close  to  the  sternuni,  and  a.  diastolic  hruit  is  heard  loudest  at  the  loicer 
extremity  of  this  hone.  In  some  instances  these  murmurs  are  heard  only 
at  mid-sternum,  about  on  a  level  with  the  third  costal  cartilages.  In  others 
they  are  most  intense  in  the  second,  and  even  the  third  intercostal  space, 
close  to  the  left  edge  of  the  sternum.  Upon  the  exclusion  of  aneurism,  a 
bruit  within  these  precincts  is  presumably  aortic  and  not  pulmonary,  espe- 
cially if  the  right  ventricle  is  unenlarged. 

Pericardial  Murmurs. — A  ])ericardial  is  distinguished  from  a  pleuritic 
friction  nuiinly  by  the  tinu'  and  locality  of  its  occurrence.  Grating  in  the 
pericardium  obviously  is  limited  to  tlie  pra'cordial  region,,  and  is  regulated 
by  the  action  of  tlie  heart.  That  of  the  pleura  is  most  prone  to  take  place 
in  itie  infra-axillary  regions,  where  pulmonary  mobility  is  extensive.  It  is 
dependent  upon  the  respiratory  movements. 

Venous  Murmurs. — In  quality  venous  murmurs  are  blowing,  cooing, 
and  sometimes  musical;  and  from  the  frequent  resemblance  of  the  noise 
to  that  of  a  humming-top,  it  has  been  denominated  venous  hum. 

It  is  usually  most  distinct  at  the  loiver  third  of  the  external  jugular 
veins,  and  more  distinct  in  the  right  than  in  the  left  side.  It  is  always  con- 
tinuous in  rhythm,  but  the  intensity  is  often  remittent  because  of  the 
])eriodical  acceleration  of  the  stream  by  the  action  of  the  heart.  The  direc- 
tion is  downward  and  inward  along  the  subclavian  and  right  innominate 
veins,  so  that  it  is  now  and  then  audible  through  the  aortic  area,  and  can  bo 
separated  with  a  little  care  from  the  aortic  sounds  as  well  as  from  the 
respiratory  murmur.  When  there  is  a  question  as  to  whether  or  not  a  given 
bruit  is  venous  or  arterial,  pressure  upon  the  vein  above  the  stethoscope  will 
stop  tlie  downivard  current  and  silence  the  venous  hum. 


in  LM(  L\  ARV  STENOSIS. 


369 


Cerebral  Blowing. — A  l)lo\ving,  systolic  murmur,  of  variable  intensity, 
is  frequently  heard  over  the  anterior  fontanel  and  sometimes  over  the 
carotids  of  children,  between  the  ages  of  three  months  and  six  years.^ 


PuLMOXAiJY  Stenosis  (Coxc4exital  Heart  Lesion:    IiLte  Baby). 

wluMi  si'vt'u  montlis  old. 


A.  X.  H.,  born  May  7,  1904,  was  fust   seen  by 
f'onsnltation  with  Dr.  E.  D.  Ledeniian. 

Fnmilj/  Hififori/ — Tt  was  tlie  third  child  bi>ni  witli  natural   labor.     Tl 
has  had  one  still-l)irtli  and  ono  miscarria":'.     lias  dii,'  cliibl  .i  \cars  old  in  ts' 


moth 


•LOUD  SYSTOLIC 
MURMUR. 


'SYSTOLIC  MURMUR. 

(very  foroible  thrill 
tiaiiAHiitted  on  palpation.) 


Dotted  inner  line  denotes 
normal  area  of  heart.  Sliaded 
line  around  heart— area  of 
cardiac  dullness  on  percussion. 


Fi<i.  110. — Case  of  Pulmonary  Stenosis — (onoeiiital — Blue  Babv.      (Original.) 


with  no  evidence  of  jieart  trouble.  Both  fatlier  and  mother  are  in  excellent  liealth, 
and  there  is  no  evidence  of  heart  or  lung  trouble,  and  no  specific  disease  on  either 
side.  This  child  has  been  cyanotic.  The  toe  nails  and  fingL^r  nails  show  tj'pical 
(dubbing  an<l  also  blueness.  On  t"ne  slightest  exertion  tlie  infant's  skin  assumes  a 
very  dark  liluc  color.  Dyspncea  is  also  present.  Th;-  culan;ous  circulation  is  very 
pool'  and  till-  nurse  informed  me  tlial  foi'  one  half  hour  after  a  tid)  bath  there  is  an 
increased   cNidence  of  cyanosis. 

.\  loud  blowing  systolic  nnirmur  could  1>.'  made  out  in  llu'  second  intercostal 
s|>ace.  There  was  also  a  weakness  of  Ihe  pulmonary  second  sound.  The  area  of 
didlness  wa.s  increased  so  that  a  right  sided  liypertrophy  undoubtedly  existed.  Tlu": 
murmur  was  not   transmitted   to  tlie  vessids  of  the  neck. 

'{"he  infant  was  breast-fed  by  its  mother  for  four  and  onedialf  months.  There 
has  hccii  a   tendency  to  constipation.     The  stool  has  been  green  and  contnined  \\hit> 


1  I  am  indebted  to  S.  S.  Burt  &  E.  Le  Fevre  for  some  points  in  tin'  abnvc  article. 


370  DISEASES  OP  THE  HEART. 

curds  at  times.  During  the  last  few  months  the  feeding  consisted  of  equal  parts  of 
barley  ^ater  and  milk.  When  seen  again  the  appetite  was  poor.  The  tongue 
slightly  coated.  The  general  condition  one  of  restlessness  by  day  and  insomnia 
by  night  The  infant  was  very  sensitive  to  cold  and  had  a  diffuse  bronchitis 
associated  with  acute  rhinitis.     I  ordered: — 

IJ  Raw  milk 12  ounces 

Rice  water 24  ounces 

Granulated  sugar  6  drachms 

Lime  water 6  drachms 

Peptogenic  milk  powder  2  measures 

Divide  in  six  bottles.     Feed  every  3  V»  hours. 

As  the  food  agreed  very  well,  I  ordered  1  ounce  more  of  milk  to  the  total 
quantity  every  second  day  until  the  infant  received  full  milk  undiluted. 
I  ordered  to  relieve  the  dyspnoea  and  regulate  the  heart: — 

IJ  Sodium  iodide   15  grains 

Sparteine  sulphate 3  giains 

Elix.  lactopeptin    2  ounces 

Half  teaspoonful  three  times  a  day. 

The  progress  of  the  case  was  excellent.  When  first  seen  by  me  there  was  no 
evidence  of  dentition.  At  the  ninth  month  the  child  had  two  teeth  and  showed 
signs  of  general  development. 

Prognosis. — As  a  rule  the  outcome  of  these  cases  is  bad,  although  I 
have  known  a  child  with  a  pulmonary  stenosis  for  the  last  twelve  years. 
He  is  now  18  years  old  and  is  able  to  do  light  work.  These  cases  have  a  tend- 
ency to  pulmonary  disease,  and  are  especially  prone  to  develop  tubercu- 
losis. 

Persistence  of  the  Ductus  Arteriosus  Botalli. 

During  the  first  four  weeks  after  the  birth  of  an  infant,  the  ductus 
arteriosus  is  closed  by  an  overgrowth  of  the  cells  in  its  inner  wall.  When 
abnormal  conditions  exist,  such  as  septic  infection  of  the  new-born  with 
thrombi,  a  breaking  down  of  the  cell  growth  takes  place  and  results  in  the 
duct  remaining  patent.  This  may  also  result  from  defective  respiration 
and  an  anomalous  pulmonary  circulation. 

The  clinical  symptoms  of  the  patency  of  the  ductus  arteriosus  are 
rapid  hypertrophy  and  dilatation  of  the  right  ventricle,  with  co-existing 
dilatation  of  the  pulmonary  artery.  There  is  also  an  increased  area  of 
cardiac  dullness.  Loud  systolic  murmurs  are  heard  all  over  the  chest  and 
a  thrill  of  the  anterior  chest  wall  can  be  felt.  Protrusion  of  the  upper  part 
of  the  sternum — dyspnoea  rarely — cyanosis  and  a  deathly  pallor. 

Gerhardt  states  that  dullness  is  found  at  the  border  of  the  second  rib; 
in  which  region  the  systolic  pulsation  of  the  pulmonary  artery  can  be  felt. 


ENDOCARDITIS. 


371 


M.  G.,  four  months  old.  Was  two  weeks  prematurely  bom.  She  was  the 
second  child.  The  first  child  died  of  diphtheria;  it  was  also  prematurely  born,  and 
died  when  its  mother  was  four  months  pregnant  with  the  present  baby.  The  mother 
had  a  normal  pregnancy,  but  was  greatly  troubled  with  headaches  and  dizziness,  and 
suffered  mentally  over  the  loss  of  the  first  child. 

The  Baby. — When  the  baby  was  six  weeks  old  the  mother  first  noticed  that  it 
breathed  with  difficulty.  It  had  been  vomiting  continuously.  Diarrhoea  has  existed 
for  ten  weeks.  There  is  an  occasional  cough.  Since  two  weeks  the  baby  appears 
colicky  and  cries  with  apparent  pain. 

Stat.  Prccs. — A  pale,  very  anaemic  looking  child,  with  large  fontanel,  somewhat 
depressed,  the  size  of  a  silver  quarter. 

The  Eyes. — There  was  a  slight  exophthabnus.  The  nose,  somewhat  depressed. 
Slight  coryza. 

The  Heai't. — The  area  of  dullness  extends  from  the  right  side  to  the  left  border 
of  the  sternum,  corresponding  to  the  lower  border  of  the  third  rib.      The  apex  is 


FRONT, 


Fig.  117. — Child  with  Persistence  of  the  Ductus  Arteriosus  Botalli.    X  Loud 
murmur  audible — blowing  presystolic.     (Original.) 

at  the  lower  border  of  the  fifth  rib,  immediately  under  the  mamilla.  The  heart  U 
somewhat  enlarged  toward  the  left  side. 

Auscultation. — A  loud  presystolic  murmur  is  heard  over  the  whole  area  of  the 
heart.  There  is  marked  abdominal  respiration.  The  lungs  are  normal  in  percussion. 
Moist  rftles  can  be  heard  over  both  lungs. 

TTie  Abdomen. — ^The  abdomen  is  distended  and  is  tympanitic  on  percussion.  It 
feels  doughy  on  palpation.  There  is  no  cyanosis  of  the  fingers  or  toes.  There  is 
a  mild  dyspnoea.  The  adipose  tissue  is  not  very  apparent.  There  is  marked 
prominence  of  the  subcutaneous  veins  of  the  scalp. 

The  clinical  history  of  the  mother  did  not  give  any  evidence  of  miscarriage, 
no  syphilis,  and  no  family  tuberculosis. 


Endocarditis. 

This  disease  is  of  frequent  occurrence  during  infancy  and  childhood. 
Congenital  endocarditis  has  frequently  been  reported,  so  that  it  is  assumed 
it  must  have  existed  during  foetal  life. 


372  DISEASES  OP  THE  HEART. 

Etiology. — Gerhardt  and  Bednar  believe  that  the  disease  occurs  quite 
frequently  in  young  children,  although  the  greatest  frequency  is  noted 
between  the  sixth  and  the  twelfth  years.  Acute  rheumatism  is  very  fre- 
quently folloAved  by  endocarditis.  Chorea  is  also  frequently  accompanied 
by  endocardial  disease.  Scarlet  fever,  measles,  variola,  varicella,  diph- 
theria, typhoid,  and  tuberculosis,  according  to  Reimer,  are  frequently  fol- 
lowed by  or  associated  with  endocarditis.  When  endocarditis  follows  pneu- 
monia, pleurisy,  or  bronchitis,  it  is  due  to  the  invasion  of  pathogenic  bac- 
teria. These  are  the  staphylococcus,  according  to  Frankel  and  Sanger,  and 
the  pneumococcus,  according  to  Netter  and  Weichselbaum.  The  germs 
enter  the  deeper  portion  of  the  pericardium  through  the  epithelium,  causing 
inflammatory  conditions.  It  is  quite  likely  that  endocarditis  is  caused  by 
such  invasion  in  acute  joint  inflammations,  in  phlegmonous  periostitis, 
lymphangitis,  pericarditis,  myo-carditis,  and  puerperal  infections.  Bouchut 
has  reported  cases  of  endocarditis  following  erythema  nodosum  and  hered- 
itary syphilis.  Von  Duscli  has  reported  endocarditis  following  extensive 
burns  of  the  hand. 

Pathology. — The  lesions  occur  most  frequently  on  the  valves  of  the 
heart.  The  valves  on  the  left  side  of  the  heart  are  most  frequently  affected, 
lience,  the  mitral  is  the  seat  of  the  lesions  more  often  than  the  aortic  valve. 
In  studying  a  series  of  these  cases  given  by  Steffen,  we  find  that  about  4 
per  cent,  show  lesions  in  the  aortic  valve. 

The  pathological  changes  consist  in  hyperaemia,  swelling,  and  an 
infiltration  of  normal  cells  or  new  connective  tissue  cells  having  a  grayish- 
white  color.  There  is  a  breaking  down  of  tlie  epithelium  besides  wart-like 
excrescences  called  vegetations  are  formed  on  the  free  border  of  the  thick- 
ened valves  (endocarditis  verrucosa).  The  result  caused  by  the  last-named 
condition  is  that  the  vegetations  prevent  a  proper  closing  of  the  valves, 
which  latter  results  in  insufficiency  and  stenosis.  Fibrinous  deposits  are 
frequently  noted  on  the  valves,  and  on  being  carried  with  the  circulation 
may  lodge  in  the  cerebral  arteries,  causing  either  emboli  or  infarctions, 
according  to  Virchow.  The  last-named  condition  is  exceptional  in  acute 
endocarditis. 

Symptoms. — Endocarditis,  whether  primary  or  secondary,  begins  with 
fever.  Not  infrequently  the  temperature  rises  to  102°,  sometimes  103° 
F.,  and  there  is  a  corresponding  increase  in  the  pulse-rate.  The  puise  is 
rapid,  irregular,  and  of  low  tension.  Cyanosis  is  sometimes  present,  espe- 
cially so  if  myocarditis  accompanies  the  attack.  Sometimes  a  child  will 
develop  endocarditis  without  any  special  symptoms  being  present.  Not 
until  the  heart  is  examined  will  the  condition  be  diagnosed.  Thus  an 
important  rule  which  has  been  previously  mentioned  is  the  necessity  of 
always  listening  to  the  heart  when  a  diagnosis  is  uncertain.  Frequently 
a  few  days  will  pass  without  specific  symptoms  being  recognized.    A  child 


ENDOCARDITIS.  373 

will  show  evidence  of  malaise  and  suddenly  the  characteristic  blowing  sys- 
tolic murmur  will  be  heard  at  the  apex.  The  murmur  is  usually  trans- 
mitted to  the  left  and  can  also  be  heard  behind.  It  is  frequently  accom- 
panied by  the  thrill  and  by  an  accentuated  pulmonic  second  sound.  When 
dilatation  results  there  will  be  a  cardiac  insufficiency.  The  murmur  may 
gradually  increase  in  intensity  and  in  the  same  manner  it  may  diminish 
until  it  is  inaudible.  When  fever  suddenly  appears  during  the  course  of 
an  attack  of  chorea,  endocarditis  should  be  suspected.  In  some  cases 
dyspnoea  may  be  present. 

The  diagnosis  is  frequently  obscure  because  a  child  will  have  no  symp- 
toms of  a  definite  nature.  If,  however,  we  are  patient  and  carefully  ex- 
amine the  heart,  we  may  be  rewarded  by  making  the  diagnosis.  It  is  im- 
portant to  examine  all  the  organs  of  the  body  before  making  a  positive 
diagnosis,  if  obscure  or  no  cardiac  symptoms  exist. 

Inspection  will  always  show  a  rapid  and  diffuse  apex-beat. 

Palpation  will  confirm  this  observation  and  may  reveal  a  strong  but 
irregular  heart  action. 

Fere  I  (ss  ion  is  usually  negative. 

Physical  signs  are  due  to  (a)  insufficiency,  (&)  roughening,  (c)  ste- 
nosis, depending  on  changes  in  the  valves.  The  character  of  the  murmur 
depends  on  the  valve  involved  and  the  lesion  of  the  valve.  In  mitral  regur- 
gitation ice  have  a  systolic  murmur  with  greatest  intensity  over  the  apex.  It 
is  usually  transmitted  to  the  side,  and  also  heard  behind  the  sternum. 

In  mitral  stenosis  we  have  a  presystolic  murmur  with  the  greatest 
intensity  over  the  mitral  area. 

In  aortic  regurgitation  ive  have  a  diastolic  murmur  tvith  the  greatest 
intensity  over  the  aortic  valve,  and.  transmitted  down  the  sternum. 

In  aortic  roughening  we  have  a  systolic  murmur  with  the  greatest 
intensity  over  the  aortic  valve.  Distinct  murmurs  can  be  heard  at  the 
valves  of  the  right  side. 

An  embolism  in  some  portion  of  the  body  is  frequently  the  sign  of  a 
lioart  lesion.  If  the  embolus  reaches  the  brain,  hemiplegia  is  the  usual 
result.  If  it  reaches  the  lungs  severe  dyspnoea  may  result.  An  embolus 
in  the  mesentery  may  result  in  diarrhoea.  If  in  the  kidneys,  hajmaturia  may 
result.     When  it  reaches  the  limbs  it  means  an  obstructed  circulation. 

Prognosis  and  Course. — Endocarditis  if  carefully  managed  with  rest 
and  strengthening  diet  will  improve.  I  have  seen  children  with  endocardial 
murmurs  improve  after  a  few  weeks,  when  put  to  bed  amid  quiet  surround- 
ings. As  a  rule  the  prognosis  is  bad  and  the  course  of  the  disease  tends 
to  become  chronic.  In  giving  an  opinion  as  to  the  outcome  of  a  case  of 
valvular  lesion,  we  must  remember  that  we  are  dealing  with  a  damaged 
heart,  and  that  months  or  years  may  pass  before  recovery  can  take  place. 
A  fatal  outcome  will  be  the  result  of  carelessness  or  mismanaoement. 


374  DISEASES  OF  THE  HEART. 

Treatment. — ■N'othing  will  do  more  good  than  absolute  rest  in  bed. 
Small  doses  of  codein  or  Dover's  powder  act  very  well.  If  endocarditis 
accompanies  or  follows  rheumatism  then  the  salicylates  should  be  given. 
An  ice-bag  over  the  heart  is  frequently  useful.  If  the  pulse  is  very  rapid 
or  the  heart's  action  is  feeble,  then  digitalis  or  strophanthus  should  be 
given. 

The  tincture  or  an  infusion  of  digitalis  made  from  English  leaves  is 
the  best.  A  point  to  remember  is  that  digitalis  has  frequently  an  accu- 
mulative effect  so  that  the  pulse  must  be  carefully  guarded  during  its 
administration.  When  this  is  the  case  the  administration  of  the  tincture 
of  strophanthus  will  be  found  very  serviceable.  In  some  children  digitalis 
will  be  badly  borne  owing  to  its  irritant  action  on  the  gastric  mucous 
jnembrane.    In  such  cases  sparteine  or  strophanthus  should  be  prescribed. 

Adrenalin  chloride  solution  taken  internally  increases  the  blood  pres- 
sure, stimulates  the  heart,  and  retards  the  pulse-rate.  It  is  better  than 
digitalis,  as  it  does  not  irritate  the  gastric  mucous  membrane,  and  it  is 
non-cumulative. 

IJ  Sol.  adrenalin  chloride 1-1000 

Infants  of  1  year,  1-5000,  made  with  normal  saline  solution. 
Dose:      Five  to  10  drops,  three  times  a  day,  gradually  increased  until  effect 
on  pulse  is  manifested. 

In  some  cases  marked  benefit  will  follow  the  use  of  iodide  of  sodium 
in  doses  of  1  to  5  grains,  according  to  age.  The  iodides  seem  to  steady  the 
heart's  action.    I  have  found  excellent  results  following  their  use. 

Malignant  Endocarditis. 

This  is  commonly  called  ulcerative  endocarditis.  It  is  a  rare  condition 
in  childhood.  Harris  reports  a  case  in  a  child  4  years  old.  The  type  of 
the  disease  is  similar  to  that  noted  in  adults.  This  condition  is  rarely 
primary.  It  occurs  with  scarlet  fever,  erysipelas,  pneumonia,  rheumatism, 
and  septicaemia,  in  which  bacterial  invasions  of  streptococci  or  pneumococci 
occur.     These  germs  are  found  in  the  endocardium. 

Pathology. — Vegetations  usually  occur  with  ulcerations  in  the  cavities 
and  on  the  valves.  Suppuration  of  the  deeper  tissues  with  abscess  forma- 
tion is  frequently  noted.  Osier  states  that  the  difl'crent  parts  of  the  heart 
are  affected  in  the  following  manner:  mitral  valve,  aortic,  mitral  and  aortic 
combined,  tricuspid  and  pulmonic  valves,  and  the  cardiac  wall.  The  sec- 
ondary lesions  of  malignant  endocarditis  are  due  to  emboli.  These  are 
most  frequeut  in  the  spleen  and  kidney,  next  in  the  brain,  intestines,  and 
skin,  and,  if  the  right  side  of  the  lieart  is  diseased,  in  the  lungs.  These 
emboli  lead  to  the  formation  of  red  or  white  infarctions,  to  haemorrhages, 


PERICARDITIS.  375 

or  to  multiple  abscesses  in  the  various  organs  and  tissues  in  which  they 
lodge. 

Symptoms. — It  is  extremely  difficult  to  diagnose  malignant  endocar- 
ditis. The  presence  of  symptoms  of  pyaemia  or  septicaemia,  associated  with 
a  heart  murmur,  usually  renders  the  diagnosis  positive.  There  is  a  remit- 
tent type  of  fever,  occasionally  delirium  and  extreme  prostration.  The 
cerebral  symptoms  frequently  suggest  meningitis.  There  is  sometimes  a 
faint  mitral  regurgitant  murmur.  Not  infrequently  it  is  entirely  absent. 
The  spleen  is  usually  enlarged.  Haemiplegia  as  well  as  hasmaturia  and  rapid 
swelling  of  the  spleen,  or  possibly  symptoms  of  pneumonia,  are  frequently 
the  result  of  emboli. 

Diagnosis. — This  is  at  times  extremely  difficult.  An  examination  of 
the  blood  for  plasmodia  will  usually  be  the  means  of  excluding  malaria  if 
the  same  is  suspected. 

Prognosis  and  Course. — The  rapidity  of  the  onset  and  the  malignancy 
of  the  disease  go  hand  in  hand.    The  outcome  is  usually  fatal. 

Treatment. — In  addition  to  rest  and  a  supporting,  stimulating  diet, 
nothing  but  relief  of  individual  symptoms  by  routine  treatment  can  be 
given. 

Pericarditis.* 

This  disease  may  exist  with  or  without  myocarditis  or  endocardial 
involvement.  Large  effusions  occur  more  readily  in  children  than  in 
adults. 

Etiology  and  Causes. — Eheumatism  is  the  most  frequent  cause  of 
pericarditis.  Apparent  mild  forms  of  rheumatism,  such  as  are  frequently 
called  "growing  pains"  by  the  laity,  are  quite  often  complicated  by  peri- 
carditis. In  this  manner  the  existence  of  the  rheumatism  preceding  the 
pericarditis  is  strikingly  brought  out. 

Pericarditis  is  rarely  a  primary  condition.  Septic  infection  of  the 
umbilicus  occasionally  causes  this  condition. 

Tuberculosis,  scarlet  fever,  diphtheria,  measles,  typhoid,  and  influ- 
enza frequently  precede  a  pericarditis. 

Baginsky  found  purulent  pericarditis  associated  with  phlegmonous 
erysipelas,  grave  forms  of  angina,  caries  of  the  ribs,  fibrinous  pneumonia, 
broncho-pneumonia,  gastro-enteritis,  furunculosis,  phlegmon  of  the  throat, 
and  empyema.    It  not  infrequently  follows  kidney  disease  and  scurvy. 

Pericarditis  is  met  with  at  any  age.  It  has  been  met  with  in  the  foetus 
according  to  Billard,  Bednar,  Hiiter,  and  Steffen. 

Bacteriology. — We  most  frequently  meet  with  a  staphylococcus  anreus 
.or  streptococci,  bacterium  coli,  and  the  diplococcus  pneumonia. 


'  The  anatomical  outlines  are  illustrated  and  described  in  the  article  on   "Tha 
Heart  and  Circulation."     See  "Introductory,"  Part  V, 


376  DISEASES  OF  THE  HEART. 

Pathology. — Pericarditis  may  be  divided  into: — 

(a)  Plastic  pericarditis. 

(b)  Pericarditis  with  serous  or  purulent  effusion. 

(c)  Adherent  pericarditis. 

Any  of  the  above-mentioned  varieties  consists  of  an  inflammatory 
affection  involving  the  serous  covering  of  the  heart  and  its  reflection  on 
the  inner  surface  of  the  pericardial  sac. 

Symptoms  and  Diagnosis.  —  The  acute  condition  begins  with  fever 
reaching  as  high  as  104°  F.  in  some  instances.  Associated  with  this  there 
is  pain  in  the  precordial  region.  Dyspnoea  is  present.  There  may  be  left 
pleurothotonos  (a  bending  of  the  body  to  one  side).  The  pulse  is  usually 
rapid.  When  there  is  effusion  the  child  will  complain  of  either  very  sharp 
pains  or  merely  a  sense  of  heaviness  and  discomfort.  Syncope,  singultus, 
and  severe  manifestations  are  present  in  the  severer  types  of  the  disease. 
Not  infrequently  there  may  be  delirium,  twitching,  and  cerebral  symptoms 
simulating  meningitis.  When  effusions  are  abundant  cyanosis  frequently 
occurs. 

The  physical  signs  resemble  those  of  adults.  In  dry  pericarditis  a 
double  friction  sound  is  heard  over  the  praecordial  space.  The  area  is  small 
and  near  the  base  of  the  heart.  The  sound  is  not  transmitted  and  is  inde- 
pendent of  the  respiratory  movement.  If  effusion  takes  place  the  apex- 
beat  will  be  found  displaced,  sometimes  upward  and  outward  or  indistinct; 
in  some  instances  it  cannot  be  found  at  all.  There  may  be  bulging  of  the 
chest  wall.  The  intercostal  spaces  become  very  prominent.  On  palpation 
there  is  an  absence  of  vocal  fremitus  over  an  area  usually  occupied  by  the 
lung. 

Percussion  gives  an  area  of  marked  dullness  or  flatness  of  triangular 
shape,  the  base  being  below  and  the  apex  above.  The  normal  area  of  car- 
diac dullness  is  increased  in  all  directions,  and  this  dullness  extends  beyond 
the  limits  of  the  heart.  On  auscultation  the  heart  sounds  are  feeble  and 
distant.  Friction  sounds  disappear  as  serum  is  poured  out,  and  reappear 
as  it  is  absorbed.  Endocardial  murmurs  may  also  be  pesent.  In  infants 
physical  signs  are  often  entirely  wanting,  or  the  normal  sounds  may  be 
feeble,  distant,  or  absent. 

The  usual  duration  of  acute  pericarditis  is  from  one  to  three  weeks. 
The  ordinary  dry  form,  with  the  resulting  adhesions,  may  be  followed  by 
a  subacute  or  chronic  form  of  the  disease.  In  the  sero-fibrinous  form  the 
serum  is  usually  absorbed  quite  promptly,  and  only  adhesions  are  left  or 
a  chronic  inflammation  follows,  with  exacerbations  in  each  recurrence  of 
rheumatism.  In  the  purulent  form  of  the  disease  in  young  children,  death 
is  the  most  frequent  termination.  If  the  pus  is  evacuated  or  spontaneous 
opening  takes  place,  there  may  be  recovery,  but  always  with  more  or  less 
extensive  adhesions  remaining. 


CHRONIC  PERICARDITIS  WITH  ADHESIONS.  377 

Prognosis. — The  prognosis  should  always  be  looked  upon  as  very  grave. 
Steffen  states  that  out  of  35  cases,  only  6  recovered.  When  this  disease 
follows  pyasmia,  or  when  it  is  a  sequela  to  the  acute  infectious  diseases,  the 
prognosis  is  very  bad.  When  it  is  associated  with  rheumatism  the  ultimate 
result,  by  reason  of  adhesions  and  dilatation,  are  usually  very  serious. 

Treatment. — Children  affected  with  acute  pericarditis  should  be  put 
to  bed  and  kept  quiet.  An  ice-bag  placed  over  the  heart  aud  small  doses 
of  opium  or  Dover's  powder  seem  to  steady  the  heart's  action.  The  value 
of  aconite  in  this  disease  must  not  be  forgotten,  especially  when  we  have 
excessive  heart's  action.  Very  bad  effects  have  been  noted  by  me  when 
either  pilocarpine  or  jaborandi  was  given.  The  specific  effect  of  salicylate 
of  soda,  salol,  or  salophen  must  be  remembered  if  due  to  rheumatism. 

Aspiration  of  the  Pericardiuvi. — When  symptoms  of  collapse,  cyanosis, 
irregular  pulse,  and  severe  dyspDoea  are  present,  then  aspiration  may  do 
good.  If,  on  aspiration,  we  find  pus  present,  an  incision  should  be  made 
and  drainage  should  be  used  as  we  would  in  a  case  of  empyema.  The  proper 
place  to  puncture  the  pericardium  is  a  point  a  little  to  the  left  of  the 
border  of  the  sternum  in  the  fifth  intercostal  space,  the  needle  being  directed 
upward  and  outward.  It  must  be  remembered  that  by  this  means  only 
can  relief  be  expected.  Keating  states  that  "of  18  cases  punctured  only  4 
recovered.'* 

Chronic  Pericarditis  vs^ith  Adhesions. 

When  children  suffer  with  repeated  attacks  of  rheumatism  complicated 
by  pericarditis,  a  chronic  pericarditis  frequently  remains.  Holt  describes 
a  case  of  a  child  sixteen  months  old,  in  which  the  pericardial  sac  was  com- 
pletely obliterated.  Associated  with  this  condition  we  frequently  have 
chronic  myocarditis,  hypertrophy,  dilatation,  and  valvular  lesions,  so  that 
no  portion  of  the  heart  muscle  or  its  lining  membrane  is  normal. 

Symptoms  and  Diagnosis. — According  to  Broadbent  there  is  a  con- 
traction seen  behind  in  the  infra-scapular  region,  sometimes  on  the  left, 
sometimes  on  the  right  side,  in  the  region  of  the  eleventh  or  twelfth  rib. 
Anteriorly  we  have  the  characteristic  signs.  They  are  a  systolic  retraction 
of  the  chest  at  or  near  the  apex  of  the  heart,  sometimes  at  the  tip  of  the 
sternum.  This  is  due  to  the  external  pericardial  adhesions,  and  is  often 
better  made  out  by  palpation  than  by  inspection.  After  the  systole  there 
is  a  rapid  rebound  known  as  the  diastolic  shock.  A  collapse  of  the  cervical 
veins  during  the  diastole  of  the  heart,  known  as  Friedreich's  sign,  is  also 
seen.  Sometimes  we  see  an  inspiratory  swelling  (Kussmaul).  In  addition 
the  pulsus  paradoxus  is  significant  of  the  presence  of  pericardial  adhesions, 
or  rather  of  the  dilatation  that  succeeds  the  adhesions.  The  pulse  is  small 
and  feeble  during  inspiration,  assuming  greater  strength  during  the  period 
of  expiration. 


378  DISEASES  OF  THE  HEART. 

Percussion  shows  an  increase  in  the  cardiac  dullness  in  all  directions. 
The  position  of  the  apex  and  the  percussion  outline  of  the  heart  do  not 
change  with  the  posture  of  the  patient,  and  the  cardiac  dullness  is  but 
little  affected  by  full  inspiration.  A  systolic  murmur  is  often  present. 
The  diagnosis  of  adherent  pericardium  always  presents  difficulties,  but  it 
can  be  made  with  tolerable  certainty  in  a  considerable  portion  of  the  cases. 
On  account  of  the  enlargement  of  the  heart  and  the  frequency  of  murmurs, 
it  is  usually  mistaken  for  valvular  disease.  The  lesion  is  a  permanent  one 
and  tends  to  increase.  If  a  child  suffers  with  valvulitis  and  the  symptoms 
do  not  yield  to  digitalis,  then  adhesive  pericarditis  should  be  suspected. 

Treatment. — There  is  no  known  method  of  treatment  which  will  mod- 
ify or  improve  this  condition,  excepting  a  supporting  diet  with  absolute 
rest  in  bed  and  general  restorative  treatment.  It  is  very  important  to 
watch  the  emunctories  and  stimulate  them  if  their  action  is  sluggish. 

Tuberculosis  of  the  Pericardium. 

This  condition  is  rarely  met  with  as  a  primary  process;  it  is  chiefly  met 
with  as  a  secondary  process.  It  usually  partakes  of  a  general  tuberculous 
process  in  which  all  the  organs  of  the  body  participate,  among  them  the 
pericardium. 

Diagnosis. — The  diagnosis  of  this  condition  depends  on  the  symptoms 
which  usually  accompany  pericarditis.  The  tubercular  nature  of  the  dis- 
ease must  depend  on  the  presence  of  tubercle  bacilli  in  the  exudation, 
although  linger  denies  the  possibility  of  making  such  a  diagnosis.  Most 
probably  a  positive  diagnosis  will  be  made  as  in  many  obscure  lesions- 
post-mortem. 

The  treatment  is  the  same  as  that  previously  described  in  the  article 
on  "Acute  Pericarditis.*' 

Htdropericardium. 

Occasionally  we  meet  with  cases  in  which  the  symptoms  of  dyspnoea 
and  cyanosis  rapidly  develop.  Steffen  maintains  that  such  alarming  symp- 
toms frequently  occur  witliin  a  few  hours,  and  that  the  same  will  some- 
times disappear  under  appropriate  treatment  in  a  few  days. 

Pathology. — A  transudation  of  serous  liquid  in  the  pericardium  with- 
out inflammatory  process,  is  usually  a  secondary  condition  in  which  drop- 
sical effusions  appear.  Usually  hydrsemic  conditions  of  the  blood,  such  as 
the  result  of  long  continued  fevers  in  infectious  diseases,  tuberculosis 
among  others,  predispose  to  this  condition. 

The  prognosis  depends  upon  the  cause  leading  to  this  condition. 

The  treatment  is  chiefly  restorative,  and  will  depend  on  maintaining 
the  strength  of  the  child  by  careful  diet  and  hygiene. 


MYOCARDITIS.  879 

Myocarditis. 

An  inflammatory  condition  involving  the  heart  muscles;  may  be  either 
acute  or  chronic.  It  occurs  as  (a)  parenchymatous,  (h)  interstitial. 
Steffen  has  reported  33  cases.  It  is  met  with  more  often  in  boys  than  in 
girls. 

This  affection  is  very  frequently  seen  during  the  convalescence  of 
diphtheria.  It  is  also  a  frequent  complication  of  scarlet  fever.  I  have  met 
this  complication  in  the  wards  of  the  Willard  Parker  and  Eiverside  Hos- 
pitals. 

Causes. — When  it  is  primary  it  is  due  either  to  rheumatism,  congenital 
syphilis,  or  tuberculosis.  Secondary,  it  is  due  to  endocarditis,  pericarditis, 
toxins  from  infectious  fevers,  or  phosphoric,  arsenic,  or  lead  poisoning. 
Traumatism  has  also  caused  myocarditis. 

Pathology. — The  heart  muscles  appear  pale,  soft,  and  friable.  The 
whole  heart  is  not  always  affected;  certain  portions  may  show  evidences  of 
degeneration  and  fatty  infiltration,  while  another  portion  may  be  normal. 
The  myocardium  is  very  susceptible  to  the  toxins  of  infectious  diseases. 
This  is  especially  ti'ue  when  diphtheria  and  scarlet  fever  have  existed  prior 
to  the  heart  lesions. 

Symptoms. — The  pulse  is  very  feeble  and  slow ;  in  some  cases  irregular ; 
in  other  cases  regular.  Sometimes  the  pulse  rate  is  increased.  The  ex- 
tremities are  usually  cold,  the  surface  of  the  skin  cool.  In  some  cases  there 
is  a  slight  rise  of  temperature,  100°  to  101°  F.  Other  cases  show  a  sub- 
normal rectal  temperature  of  96°  to  98°  F.  It  is  very  evident  that  the 
toxins  of  the  infectious  diseases  inhibit  the  proper  action  of  the  thermic 
centers.  I  have  seen  distinct  vasomotor  disturbances,  such  as  unilateral 
flushing,  affecting  one  cheek  or  the  lobe  of  one  ear.  The  child  shows  a 
marked  general  depression.  There  is  a  general  devitalization  noticeable; 
also  marked  apathy.    The  child  appears  listless  and  prefers  to  rest. 

The  Heart. — There  is  an  irregular,  very  rapid  heart's  action.  The 
lieart  sounds  are  very  indistinct.  When  the  above  symptoms  occur  during 
the  course  of  infectious  diseases,  myocarditis  should  be  suspected.  Some- 
times there  is  faintness,  severe  dyspnoea,  and  cyanosis.  Not  infrequently 
there  is  albumin  in  the  urine.  Dilatation  and  hypertrophy  sometimes  occur 
without  showing  distinct  symptoms.  The  ratio  of  the  pulse  and  respiration 
will  be  disarranged. 

Diagnosis. — In  some  cases  this  is  very  difficult  to  make.  The  presence 
of  a  slow  pulse  and  muffled  heart  sounds  during  the  beginning  or  during  the 
convalescence  of  acute  infectious  diseases,  should  always  lead  to  the  sus- 
picion of  myocarditis.  A  slow  pulse  in  itself  should  always  be  looked  upon 
as  ominous. 


380  DISEASES  OF  THE  HEART. 

Frequently  a  diagnosis  of  myocarditis  is  made  at  the  autopsy  when 
no  positive  symptoms  of  the  condition  were  present  during  life. 

Prognosis. — The  prognosis  is  certainly  not  good.  Earely  do  we  find 
cases  of  myocarditis  recover.  This  is  especially  true  when  myocarditis  com- 
plicates the  acute  infectious  diseases  and  the  child  is  in  a  devitalized 
condition. 

Treatment. — Excitement  or  exertion  may  cause  sudden  death.  The 
child  requires  absolute  rest.  It  should  be  put  to  bed  in  a  recumbent  posi- 
tion. High  saline  injections  at  a  temperature  of  115°  to  130°  F.,  using 
several  quarts  of  salt  water,  can  be  tried  two  or  three  times  a  day.  The 
diffusible  effect  of  the  hot  saline  and  consequently  the  tendency  to  eliminate 
toxins  through  the  kidney,  should  serve  as  a  valuable  therapeutic  adjunct. 
Life  can  certainly  be  prolonged  by  this  measure;  if  it  is  cautiously  done, 
80  as  not  to  exert  the  child's  heart,  the  result  will  be  apparent  very  soon. 

Another  diffusible  stimulant  which  has  served  me  very  well  is  the 
injection  of  hot  water  to  which  several  grains  of  carbonate  of  ammonia 
have  been  added.  In  some  cases  of  severe  cardiac  depression  I  have  seen 
good  results  from  the  injection  of: — 

IJ  Sp.  ammon.  aromatic V2  drachm 

Hot    water 1  quart 

Inject  through  a  rectal  tube  into  the  colon,  at  a  temperature  of  110°  to  115"  F., 
once  in  six  hours,  alternating  with  the  hot  saline. 

In  syphilis  or  tuberculous  conditions  the  treatment  should  be  specific. 
When  evidences  of  heart  failure  exist  strychnine,  caffein,  whisky,  aromatic 
spirits  of  ammonia,  and  nitroglycerine  may  be  used.  Spartein  in  small 
doees  {^/lo  grain  every  hour)  may  be  given.  The  value  of  concentrated 
food  is  greater  in  this  condition  than  in  any  other. 

Feeding. — No  drug  will  give  as  much  strength  to  the  body  as  food. 
Food  should  be  given  very  frequently  in  small  quantities.  A  cup  of  con- 
centrated chicken  broth  or  beef  broth  should  be  given,  and  two  hours  later 
the  white  of  two  or  three  raw  eggs  with  sweetened  coffee.  Milk  punch, 
cocoa,  chocolate,  or  strained  oatmeal  gruel  may  be  given.  One  of  the  above 
foods  may  be  given  every  two  hours.  Several  ounces  may  be  given  at  each 
feeding.  The -outcome  of  the  case  depends  upon  strengthening  the  heart. 
My  plan  has  been  to  give  the  strychnine  in  the  food.  Drugs  have  a  more 
diffusible  effect  and  seem  to  enter  the  circulation  better  when  combined 
with  hot  food.  If  for  any  reason  the  stomach  is  sensitive  and  does  not 
retain  food,  rectal  feeding  with  peptonized  milk  may  be  necessary  along 
with  the  hot  salines  •  previously  mentioned. 


CHAPTEE  III. 

DISEASES  OF  THE  LIVER. 

The  Liver. 

The  liver  in  nurslings  is  relatively  larger  than  in  adults.  To  examine 
the  liver  place  the  child  on  its  back  with  the  legs  slightly  flexed  toward  the 
abdomen.     Have  the  child,  if  possible,  breathe  with  regularity. 

Position  of  Liver. — Dullness  can  be  made  out  from  the  fifth  inter- 
costal space  in  the  mammary  line  to  about  one  inch  below  the  border  of 
the  ribs.  In  the  axillary  line  it  reaches  from  the  seventh  intercostal  and 
posteriorly  a  dullness  is  made  out  at  the  ninth  intercostal  space.  It  extends 
downward  and  can  best  be  made  out  by  palpating. 

Birch-Hirschfeld  found  the  average  weight  of  the  liver  in  the  new- 
born infant  about  four  and  one-half  ounces  (127  grams). 

Steffen  who  has  devoted  considerable  attention  to  the  liver  states  that 
the  left  lobe  is  relatively  larger  in  the  child  than  in  the  adult. 

Bile. 

The  quantity  of  bile  in  the  gall-bladder  is  very  small.  It  is  of  a  golden- 
yellow  color,  and  has  a  neutral  reaction.  Its  specific  gravity  varies  from 
1014  to  1053.  According  to  Baginsky  the  bile  in  nurslings  contains  or- 
ganic salts — cholesterin  and  lecithin — fat,  and  various  acids  in  less  pro- 
portion than  in  adults.  Baginsky  was  able  to  demonstrate  the  presence 
of  glycocolic  acid.  The  presence  of  a  much  less  quantity  of  bile-acids  in 
the  infant  is  a  beneficial  physiological  condition.  It  is  a  well-known  fact 
that  these  acids  inhibit  the  digestive  action  of  the  pepsin  and  of  the  pan- 
creatic juice.  Another  point  is  that  the  absence  of  a  bile-acid  prevents  the 
assimilation  of  large  quantities  of  fat,  as  it  is  impossible  to  split  up  the 
fat  into  fatty  acid  and  glycerine.  Thus,  fermentative  processes  are  much 
more  frequent  in  nurslings  and  appear  with  greater  intensity  than  in  the 
adult,  because  of  the  biliary  acids.  The  amylacea  and  all  substances  con- 
taining flour  are — owing  to  the  above-described  condition  of  the  pancreatic 
juice  and  the  bile — not  fit  substances  to  give  the  infant,  especially  during 
its  first  three  months  of  life,  although  very  small  quantities  can  be  digested, 
and  after  the  fourth  month  are  not  only  digested,  but  also  absorbed. 

Baginsky  and  Sommerfeld  found  large  quantities  of  mucin  in  the 
bile. 

Jaundice  (Icterus).* 

There  are  two  forms  of  jaundice  met  with  in  children :  first,  hepato- 
genic;   second,  haematogenic.     The  most  common  form  seen  in  children 


*  Icterus  neonatorum  is  described  in  Part  II,  "Diseases  of  the  New  Born." 

(381) 


§82  DISEASES  OF  THE  LIVER. 

is  a  catarrhal  Jaundice.  This  is  due  to  an  extension  of  the  catarrhal  process 
from  the  stomach  to  the  duodenum,  causing  catarrh  of  the  bile  ducts.  (See 
chapter  on  "Gastro-duodenitis.")  In  the  hepatogenic  form,  there  is  an 
obstruction  to  the  flow  of  bile  into  the  bowel.  It  is  also  called  obstructive 
jaundice. 

In  the  hasmatogenic  form  there  is  no  obstruction  to  the  flow  of  bile, 
but  the  jaundice  is  due  to  blood  conditions.  We  find  jaundice  in  sepsis, 
in  malaria,  and  in  typhoidal  conditions.  Mechanical  obstructions,  such  as 
round  worms  entering  the  common  duct,  have  been  reported,  but  they  are 
rarities. 

Acute  Congestion  of  the  Liver. 

In  literature  very  little  light  is  shed  on  this  condition.  Some  authors 
state  that  malaria  and  other  poisons,  particularly  phosphorus,  may  cause 
this  condition.  I  believe  that  acute  congestion  of  the  liver  is  frequently 
associated  with  acute  gastric  catarrh.  It  is  also  no  doubt  one  of  the  factors 
on  which  intestinal  indigestion  hinges.  The  symptoms  are  mainly  those 
of  enlargement  which  can  be  made  out  by  palpation  and  functional  de- 
rangement such  as  will  be  considered  in  the  next  article. 

Functional  Disorders  of  the  Liver. 

Functional  Derangement. — This  very  common  condition  is  character- 
ized by  either  a  total  absence  or  a  diminution  in  the  quantity  of  bile  secreted. 
This  functional  disorder  usually  causes  very  dry,  grayish,  or  whitish  "clay 
colored"  stools;  also  flatulence.  The  urine  is  of  a  very  dark  reddish  or 
brownish  color.  Frequently  the  skin  and  conjunctival  mucous  membrane 
is  pigmented.  The  temperature  may  reach  101°  F. ;  rarely  higher  than 
103°  F.  If  after  rest,  proper  diet,  and  hepatic  stimulation  the  fever  per- 
sists, then  the  possibility  of  abscess  in  the  gall-bladder  should  be  remem- 
bered. 

Treatment. — Calomel,  podophyllin,  or  elaterin  in  small  doses.  The 
salines  and  phosphate  of  soda  in  5  or  10-grain  doses  can  be  given.  Diluted 
hydrochloric  acid  or  diluted  nitro-muriatic  acid,  in  1-drop  doses,  is  a  good 
bile  stimulant.  In  some  cases  a  gentle  faradic  current  and  massage  may 
do  good.  A  cold  spray  over  the  liver  will  also  tone  the  same.  Large  quan- 
tities of  liquids  will  sometimes  aid  in  relieving  functional  disturbance  of 
the  liver. 

Displacement  of  the  Liver. 

The  liver  may  be  displaced  downward  when  the  ribs  are  contracted  in 
size.  This  condition  is  best  noted  in  rickets.  The  liver  may  also  be  dis- 
placed by  pleural  effusions.  It  is  found  much  lower  in  diseases  wherein 
emaciation  takes  place,  such  as  in  marasmic  or  tubercular  manifestations. 
In  these  latter  conditions  relaxation  of  the  abdominal  walls  permits  the 
liver  to  occupy  a  position  much  lower  than  normaL 


AMYLOID  DEGENERATION.  383 

Displacement  Due  to  Diseases  of  the  Adjacent  Organs. — The  liver  is 
sometimes  displaced  by  tumors  arising  in  the  right  pelvic  region,  chiefly 
from  swelling  associated  with  the  right  kidney.  In  a  case  of  mine  (see 
chapter  on  "Pyelitis")  the  kidney  pushed  the  liver  upward  and  to  the  left. 
The  liver  returned  to  its  normal  position  after  the  diseased  kidney  was 
removed. 

Several  years  ago,  at  the  Kaiser  and  Kaiserin  Friedrich  Children's  Hospital  of 
Berlin,  I  saw  a  case  of  a  child  having  a  supposed  tumor  involving  the  liver.  While 
all  believed  that  the  swelling  was  associated  with  the  liver,  after  the  abdomen  was 
opened  it  was  found  that  the  kidney  was  the  seat  of  the  trouble  and  that  the  liver 
was  unafiFected. 

Descended  Liver. 

Rowland  G.  Freeman,  in  studying  a  series  of  496  autopsies  in  children, 
states  that  he  has  met,  not  very  rarely,  with  descended  liver.  These  en- 
larged livers  were  found  in  children  suffering  with  tuberculosis  and  lobar 
pneumonia.  In  his  cases  the  liver  had  slipped  down  the  right  side  of  the 
abdomen. 

Amyloid  Degeneration  (Waxy  Liver). 

This  is  an  extremely  rare  condition.  Freeman  mentions  but  two  cases 
in  his  large  post-mortem  experience,  one  case  associated  with  tuberculous 
disease  of  the  vertebrae  and  psoas  abscess,  and  the  other  case  in  a  child 
suffering  from  progressive  ansmia.  The  liver  and  kidneys  were  waxy  in 
both  cases. 

Experimentally,  amyloid  degeneration  has  been  produced  by  the  action 
of  the  toxins  of  the  staphylococcus  pyogenes  aureus. 

Symptoms. — Special  symptoms  which  could  be  called  those  specifically 
due  to  this  condition  cannot  be  described.  The  symptoms  of  the  disease 
associated  with  amyloid  degeneration  are  present  on  palpation.  The  liver  is 
enlarged,  the  surface  very  smooth  and  hard,  without  tenderness.  The 
spleen  is  also  enlarged.  Dropsy  is  usually  present.  The  latter  symptom 
must  not  necessarily  be  due  to  the  kidney,  but  may  result  from  pressure 
of  the  swollen  liver  upon  the  vena  cava.  When  this  disease  is  associated 
with  syphilis  then  syiiiplonis  of  tljc  latter  disease  may  also  he  found. 

The  prognosis  is  usually  had. 

Treatment. — This  depends  on  tlie  symptoms  whieli  require  urgent 
iiianageiiieiit.  Syphilis  when  pre^^^ent  reciuires  anti-syphilitic  treatment. 
'I'he  outeonie  of  the  ease  de])ends  on  restorative  treatment,  including  nutri- 
tion. 

Fatty  Liver. 

Fatty  degeneration  of  the  liver  is  very  freijuently  noted  in  children. 
Woilstein  has  found  201  cases  of  fatty  liver  in  iUo  consecutive  autopsies. 
Freeman  and  Long  studied  a  series  of  2i)G  auto[)sies  at  the  Foundling  llos- 


384  DISEASES  OF  THE  LIVEtl. 

pital,  and  foimd  203,  or  about  68  per  cent.,  fatty  livers.     This  disease  is 
not  as  frequently  found  associated  with  wasting  diseases  as  is  claimed. 

The  following  classification  of  causes  or  conditions  with  which  fatty 
liver  is  associated  is  given  by  C.  Oddo,  in  Grancher's  Maladie  de 
VEnfance: — 

1.  Intoxications:    Phosphorus,  alcohol. 

2.  (a)  Infections,  acute:  typhoid  fever,  measles,  scarlet  fever,  small- 
pox, and  diphtheria,  bronchopneumonia,  acute  general  tuberculosis,  and 
diarrhoea,  (l)  Infections,  chronic:  chronic  tuberculosis,  hereditary  syph- 
ilis. 

3.  Maladies  of  nutrition:    chronic  gastro-enteritis,  rachitis. 

4.  Fatty  liver  associated  with  the  hepatic  lesions. 

Cirrhosis  of  the  Liver  (Interstitial  Hepatitis). 

Two  varieties  of  cirrhotic  liver  are  seen  in  children;  they  are:  (a) 
atrophic,  (h)  hypertrophic.  This  condition  is  caused  by  the  same  factors 
that  produce  cirrhosis  in  the  adult.  The  two  most  important  factors  that 
produce  this  condition  are  syphilis  and  the  excessive  use  of  alcohol.  Freeman 
reports  two  cases  in  neither  of  which  alcohol  was  the  cause  of  the  con- 
dition, nor  was  any  acute  disease  reported  prior  to  the  cirrhosis. 

Symptoms. — Digestive  disturbances,  such  as  fullness  in  the  abdomen, 
constipation,  or  diarrhcca  exist.  The  temperature  is  irregular.  As  a  rule 
the  liver  is  not  enlarged. 

Diagnosis. — This  is  sometimes  extremely  difficult  and  can  only  be 
determined  positively  by  a  post-mortem. 

Prognosis. — The  prognosis  depends  on  the  cause.  If  due  to  syphilis, 
the  prognosis  is  fair;  if  due  to  alcohol,  then  it  is  grave. 

Treatment. — The   treatment  of  the   case   depends   on   the   symptoms 

presented. 

Focal  Necrosis. 

This  is  usually  found  associated  with  infectious  fli?eascs.  It  has  been 
observed  resulting  from  the  toxin  of  diphtheria  and  measles.  Freeman 
found  focal  necrosis  in  4  cases  out  of  14  consecutive  autopsies  on  measles 
cases. 

Summary. — "1.  Descent  of  the  liver  down  the  right  side  of  the  abdo- 
men, so  that  the  right  lobe  reaches  below  the  crest  of  the  ilium,  occurs  oc- 
casionally in  infants,  and  particularly  in  those  in  whom  the  liver  is 
enlarged. 

"2.  Fatty  livers  occur  very  frequently  in  the  infants  and  children 
who  die  at  the  New  York  Foundling  Hospital,  or  in  about  41  per  cent, 
of  all  cases. 

"3.  The  condition  of  nutrition  of  the  'child,  as  expressed  by  the  absence 
of  fat  in  general  and  wasting  of  tissue,  aj)par('ntly  has  no  connection  with 
the  fatty  condition  of   the  liver,   the  condition  of  niiirition   in  the  eases 


SUBPHRENIC  ABSCESS.  385 

having  fatty  livers  averaging  about  the  same  as  in  the  whole  number  of 

cases. 

"4.  Fatty  livers  occur  rarely  in  the  following  chronic  wasting  diseases: 
marasmus,  malnutrition,  rachitis,  and  syphilis,  unless  such  condition  be 
complicated  by  an  acute  disease. 

"5.  With  tuberculosis  fatty  livers  occur  not  more  often  than  with  other 
conditions. 

"6.  Fatty  livers  occur  most  often  with  the  acute  infectious  diseases  and 
gastro-intestinal  disorders. 

"7.  The  two  cases  of  cirrhosis  of  the  liver  examined  by  the  writer  ran 
a  comparatively  acute  course.  The  livers  on  section  showed  a  marked 
hyperplasia  of  the  so-called  new-formed  bile  ducts. 

"8.  Focal  necrosis  of  the  liver  may  be  a  lesion  of  measles." 
Read  articles  on  "Liver,"  "Bile,"  and  "Congenital  Obliteration  of  the 
Bile  Ducts"  in  the  chapter  on  "The  New-born  Baby." 

Subphrenic  Abscess. 

This  condition  is  very  rare  in  children.  It  consists  of  an  accumulation 
of  pus  above  the  liver,  lui  'beneath  the  diaphragm.  Carl  Beck  has  described 
this  condition  in  extenso  in  a  paper  read  before  the  New  York  Academy  of 
Medicine  several  years  ago. 

Meltzer^  reports  a  case  occurring  in  a  child  2  years  old. 

Jopson-  has  recently  reported  a  case  from  the  Children's  Hospital, 
in  Philadelphia, 

MaydP  has  studied  a  series  of  179  cases.  Of  these  cases  which  were 
found  in  all  ages,  10,  or  5.9  per  cent.,  were  under  15  years  of  age.  The 
causes  in  Maydl's  cases  were  attributed  to  the  stomach  and  duodenum, 
intestinal,  pericaecal  (including  appendicitis),  echinococcus,  subcutaneous 
traumatism,  cholangitis,  perinephritis,  metastatic  wounds  and  gunshot  in- 
juries, and  caries  of  the  ribs. 

Jopson,  in  reporting  the  causes  of  12  of  his  cases,  includes  appendi- 
citis, perforated  gastric  or  duodenal  ulcer,  caries  of  the  dorsal  vertebrae, 
traumatism,  and  calculous  cholecystitis. 

In  a  case  reported  by  A.  Frederici*  a  girl,  8  years  old,  had  an  abscess 
which  ruptured  into  the  lung.  The  diagnosis  of  subphrenic  abscess,  secon- 
dary to  liver  abscess,  was  founded  on  tenderness  over  the  liver  region  before 
the  abscess  ruptured,  and  on  the  absence  of  air  in  the  abscess  cavity. 

Baginsky  reported  a  case  in  a  child,  2  V2  years  old,  secondary  to 
appendicitis. 


'  New  York  Medical  Journal,  June  24,  1893. 
*Arcliives  of  Pediatrics,  February,  1904. 
•Subphrenic  Abscess,"  Wien,   1894. 
*In  Alonatschr.  L  Kinderheilk,  July,  1903. 

26 


CHAPTEE  IV. 

DISEASES  OF  THE  SPLEEN  AND  PANCREAS. 

The  Spleen. 

One  of  the  most  difficult  organs  of  a  child  to  examine  is  the  spleen. 
It  can  be  palpated  between  the  ninth  and  eleventh  ribs.  It  is  impossible 
to  positively  outline  the  spleen  by  percussion.  For  the  purpose  of  examina- 
tion the  child  should  be  placed  flat  on  its  back  with  the  thighs  flexed.  By 
gentle  manipulation  with  the  tips  of  the  fingers,  we  can  frequently  in  a 
quiet  child  press  under  the  free  border  of  the  ribs  and  feel  the  smooth  border 
of  the  spleen.  Some  authors  maintain  that  when  the  spleen  is  palpable, 
it  is  enlarged.  I  have  frequently  been  able  to  palpate  the  spleen  in  per- 
fectly normal  infants. 

There  are  no  primary  diseases  of  the  spleen,  although  it  is  frequently 
the  seat  of  tubercular  disease. 

Enlargement  of  the  Spleen  (Splenitis). 

An  enlarged  spleen  is  frequently  seen  in  various  systemic  conditions. 
It  is  one  of  the  characteristic  symptoms  of  many  of  the  acute  infectious 
diseases.  It  is  a  prominent  symptom  of  malarial  infection  and  typhoid 
fever,  and  next  to  the  condition  of  the  blood  itself,  is  a  very  valuable  aid 
in  the  diagnosis.  In  cachectic  conditions  and  in  such  constitutional  dis- 
orders affecting  the  blood,  as,  for  example,  in  rickets,  a  very  large  spleen 
can  frequently  be  palpated.  An  enlargement  of  the  spleen  reaching  into 
the  groin  was  seen  by  me  in  a  case  of  rickets.  The  spleen,  therefore,  is  a 
very  valuable  aid  to  diagnosis  in  many  conditions.  For  a  description  of 
the  method  of  examination  see  article  on  the  "Spleen  in  the  New-born 
Baby." 

•Wandering  Spleen  (Movable  Spleen,  Lien  Mobilis). 

When  there  is  an  elongation  of  the  gastro-lienal  ligament,  the  spleen 
can  be  readily  moved. 

Causes. — Severe  paroxysms  of  coughing,  such  as  whooping-cough  or 
traumatism,  can  cause  this  condition. 

Symptoms. — In  young  children  there  are  no  special  guides.  Older 
children  complain  of  pain  on  the  left  side  and  vague  abdominal  pains, 
(386) 


THE  PANCREAS.  887 

Dia^osis. — The  diagnosis  is  made  by  palpating  the  wandering  spleen. 

Treatment. — An  abdominal  bandage  to  support  the  abdomen  will  fre- 
quently aid  in  replacing  the  spleen.  Earely  will  surgical  treatment  be 
demanded. 

The  Pancreas. 

The  pancreas  is  situated  behind  the  stomach.  It  is  about  the  height 
of  the  first  lumbar  vertebras.  The  function  of  the  pancreas  is  known  as 
the  amylolytic  function,  namely,  starch  digestion,  in  reality  the  conversion 
of  starch  into  sugar. 

Diseases  of  the  Pancreas. 

Syphilitic  tissue  changes  are  frequently  seen  in  the  pancreas.  Malig- 
nant tumors  are  occasionally  reported  in  the  literature.  When  such  lesions 
exist  they  tax  the  diagnostic  skill  of  the  specialist.  The  diagnosis  is  rarely 
made  intra  viiam. 


CHAPTER  V. 
DISEASES  OF  THE  PERITONEUAL 

Acute  Peritonitis. 

This  is  a  very  rare  condition  in  childliood.  It  is  most  frequently 
seen  in  practice  in  the  new-born,  where  the  inflammation  is  the  result  of 
a  pyogenic  infection  through  the  umbilical  vessels.  This  has  been  de- 
scribed in  the  chapter  on  the  "New-born  Baby." 

Etiology. — This  inflammation  is  frequently  the  result  of  traumatism. 
It  may  follow  the  operation  for  appendicitis  or  other  operation  on  the 
abdomen.  Cases  have  been  reported  where  an  infection  such  as  gonor- 
rhoea or  vulvo-vaginitis  has  extended  into  the  uterus  or  into  the  perito- 
neum. This, condition  may  frequently  accompany  Pott's  disease  or  peri- 
nephritis, and  may  also  follow  deep-seated  burns  in  which  cellulitis  or  ery- 
sipelatous inflammation  exists. 

I  have  seen  peritonitis  as  a  complication  of  scarlet  fever  in  hospital 
and  private  practice. 

Bacteriology. — The  streptococcus  is  most  frequently  found  to  be  the 
cause  of  peritonitis  in  the  new-born.  Sometimes  the  pneumococcus  and 
the  bacterium  coli  communi  are  found. 

Pathology. — Serous  Form:  There  is  a  large  outpouring  of  serum 
which  is  clear,  and  there  is  a  small  amount  of  lymph  associated  with  it. 
When  recovery  takes  place  the  serum  is  absorbed.  Adhesions  usually 
follow. 

Fibrinous  Form. — The  peritoneum  is  intensely  congested.  The  blood- 
vessels injected  and  a  large  amount  of  lymph  is  thrown  out  with  very  little 
serum.  The  pathological  process  corresponds  to  that  condition  seen  in 
fibrinous  pleurisy.  Firm  adhesions  resulting  in  the  formation  of  connec- 
tive tissue  bands  usually  remain. 

Purulent  Form. — A  large  amount  of  lymph  and  pus  are  present  with 
the  usual  evidences  of  inflammation.  The  abscess  is  rarely  localized  or 
isolated  from  the  rest  of  the  peritoneum  by  a  thick  wall  of  fibrin.  Spon- 
taneous evacuation  of  pus  through  the  vagina,  rectum,  bladder,  or  um- 
bilicus has  been  reported.  Such  cases  may  recover.  As  a  rule  purulent 
peritonitis  is  fatal. 

Symptoms. — The  symptoms  of  fever,  vomiting  with  pain,  and  uniform 
distention  of  the  abdomen,  are  usually  present.  There  is  also  tympanites, 
and  when  liquid  is  present  fluctuation  can  be  felt.  The  child  is  usually 
found  flat  on  its  back  with  the  legs  flexed.    Diarrhcca  exists  in  some  cases, 

(388) 


CHEOJflC  PERITO!<ITIS.  389 

constipation  in  others.    The  child  appears  very  sick  and  suffers  continuous 
pain.    The  following  case  occurred  in  my  practice : — 

Jessie  M.,  2  years  old,  had  typical  symptoins  of  influenza.  There  was  coryza, 
sneezing,  and  a  temperature  of  104°  F.  At  this  time  there  had  been  a  house 
epidemic  and  all  members  of  the  family  were  suft'ering  with  influenza.  The  child 
had  anorexia  and  vomiting,  and  cried  continuously  as  if  in  pain.  The  abdomen  was 
distended,  and  constipation  reported.  A  soap  water  enema  was  ordered,  and 
although  a  good  result  followed,  the  crying  continued.  The  abdomen  was  tympanitic 
on  percussion  and  the  uniform  distention  continued.  An  ice-bag  was  ordered,  but 
gave  no  relief.  Local  applications  of  warm  antipMoijistine  poultices  seemed  to  afford 
relief.  Chamomile  injections  at  a  temperature  of  115°  F.  were  ordered  given  into  the 
colon.  When  the  same  passed  off  another  injection  of  8  ounces  of  warm  olive  oil 
not  only  relieved  the  child  but  produced  sleep.  These  injections  were  repeated  three 
times  a  day.  Codeine  with  calcined  magnesia  was  ordered  to  relieve  pain  and  for 
the  antifermentative  effect. 

Feeding. — Whey  was  given  every  four  hours  and  several  teaspoons  of  Mulford's 
predigested  beef  with  whisky  every  two  hours.  The  disease  lasted  about  two  weeks. 
The  child  recovered. 

Prognosis. — This  disease  is  frequently  fatal,  especially  the  purulent 
variety.  The  most  favorable  cases  are  those  in  which  there  is  a  sero- 
fibrinous exudation.  The  outcome  depends  on  the  vitality  at  the  time  of 
iiiness. 

Treatment. — Warm  applications  have  served  me  best,  although  some 
authors,  especially  the  Germans,  prefer  ice.  Hot  moist  flannels,  to  which 
15  to  30  drops  of  turpentine  have  been  added,  will  usually  relieve  tyin- 
panites.  Codeine  should  be  given  until  the  child  is  comfortable,  Vio 
to  Vs  grain,  every  two  hours  or  oftener.  My  results  have  been  best  when 
milk  was  omitted.  Soup  or  broth  may  be  given.  Whey  is  valuab'e  in  this 
condition,  also  white  of  raw  egg  well  beaten  with  sweetened  water.  Tiie 
treatment  described  in  the  clin'cal  case  above  cited  is  my  usual  method 
adopted.  The  high  colon  flushings  are  cleansing  and  soothing.  When 
great  prostration  exists,  instead  of  using  chamomile  tea  and  warm  olive-oil, 
normal  saline  solution  has  a  more  toning  effect.  Special  symptoms,  such 
as  collapse,  require  strychnine,  nitro-glycerine,  or  caffeine  sodium  bonzoate. 
Also  liberal  stimulation  with  champagne  or  whisky.  Oxygen  if  cyanosis 
exists. 

Operative  Treatment. — If  symptoms  of  appendicitis  exist,  then  an 
operation  may  do  good.  If  a  sudden  collapse  is  noted  perforation  should 
be  suspected  and  the  surgeon  consulted  at  once. 

Chronic  Peritonitis   (Non-Tubercdlous). 

Many  authors  doubt  the  existence  of  a  non-tuberculous  peritonitis. 
Henoch  believes  that  we  have  a  distinct  variety  of  chronic  peritonitis  which 
bears  no  relation  to  tuberculosis. 


390  DISEASES  OF  THE  PERITONEUM. 

Symptoms. — In  a  distended  abdomen  associated  with  ascites  the  liquid 
can  be  made  out  by  palpation.  There  may  be  diarrhoea  or  there  may  be 
constipation.  Dyspeptic  symptoms  are  always  present,  and  there  is  a 
slight  rise  of  temperature.  There  are  no  other  symptoms  of  tuberculosis, 
and  as  a  rule  no  other  complications  present.  Anaemia  is  usually  very 
marked. 

A  child  8  j'ears  old  was  seen  by  me  during  my  service  in  the  German  Poliklinik. 
He  was  a  bottle-fed  and  rachitic  boy.  He  had  suffered  with  a  very  severe  acute  millc 
infection,  resulting  in  cholera  infantum  and  peritonitis.  The  child  developed 
symptoms  of  athrepsia  infantum.  Seversjil  j'ears  later  the  child  had  a  swollen  t)'m- 
paiiitic  abdomen  and  a  wave  of  fluid  could  be  made  out  by  careful  palpation.  I  aspi- 
rated about  1  pint  of  a  yellow  seaous  fluid.  The  same  was  examined  and  no  tubercle 
bacilli  or  other  bacteria  were  found.  The  condition  improved.  The  case  was  seen 
by  me  twice  a  month  and  it  was  necessary  to  tap  the  abdomen  each  time  to  relieve 
distention.  The  child  was  under  observation  about  six  years.  During  this  time 
large  doses  of  iodide  of  sodium,  codliver-oil,  and  iron  were  ordered.  A  change  to 
tiie  country  seemed  to  do  the  most  good.     The  child  is  well  to-day. 

Tuberculous  Peritonitis. 

The  peritoneum  frequently  participates  in  a  general  tuberculous  con- 
dition. It  may,  however,  be  an  entirely  independent  disease;  that  is,  it 
may  occur  as  the  primary  lesion  of  tuberculosis.  Biedcrt^  collected  a  series 
of  883  autopsies  on  tuberculous  children  of  various  ages.  He  found  the 
peritoneum  affected  in  18  j^er  cent.  The  disease  may  be  either  acute  or 
chronic. 

Pathology. — In  tubercular  peritonitis  the  lesions  are  those  of  a  general 
miliary  tuberculosis.  There  are  usually  not  very  many  tubercles  scattered 
through  the  peritoneum.  When  the  ascites  is  present  then  the  tubercles 
are  far  more  abundant.  The  omentum  and  mesentery  participate  in  the 
tuberculous  process.  The  liquid  present  may  be  brownish  colored  serum 
containing  blood;    it  may  be  serous,  or  yellowish  and  contain  pus. 

The  fibrous  form  usually  shows  adhesions  between  the  loops  of  intes- 
tine or  between  the  intestine  and  the  abdominal  wall.  In  the  ulcerative 
form  there  is  usually  a  fibrinous  exudation.  This  form  usually  follows  the 
miliary  or  fibrous  variet}'. 

Symptoms. — Well-marked  evidences  of  peritonitis  can  usually  be  made 
out,  when  ascites  and  tympanites  are  present.  When  fever  is  associated 
with  it  in  addition  to  evidence  of  cough  or  other  physical  signs  in  the  lungs, 
then  the  diagnosis  is  not  doubtful.  Sometimes  the  tubercular  or  non- 
tubercular  forms  of  chronic  peritonitis  will  render  the  diagnosis  very  diffi- 
cult. 

Differential  Points. — Cirrhosis  of  the  liver  may  cause  an  ascites.  It 
is  rare  in  very  young  children.     If  the  history  of  syphilis  is  given  the 


*  Jahrbuch  fiir  Kinderheilkunde,  xxi,  p.  178. 


TUBERCULOUS  PERITONITIS. 


891 


same  may  be  suspected.  In  some  cases  a  diagnosis  can  only  be  made  when 
an  exploratory  puncture  is  made  and  the  fluid  examined.  Even  then  the 
diagnosis  may  be  difficult.  The  only  method  then  left  is  to  make  a  micro- 
scopical examination  of  the  fibrous  nodules  or  rarely  by  inoculation  experi- 


Fig.   118. — Case  of   Tubercular   Peritonitis  Complicated  by   Tubercular 
Empyaema,      Enlarged    Spleen.      Rachitic    Bottle-fed     Infant.       (Original.) 


ments.    The  following  cases  represent  tubercular  peritonitis  as  occurring  in 
my  private  practice: — 

M.  B.,  female,  2  years  old,  was  brought  to  me  with  a  history  of  cough,  dis- 
tended abdomen,  and  severe  constipation  alternating  with  diarrhoea.  The  appetite 
was  poor,  and  the  child  had  lost  considerable  in  weight  and  has  not  been  well  since 
an  attack  of  measles  which  occurred  about  one  year  ago.  Evidences  of  tuberculosis 
were  made  out.  The  stool  contained  mucus.  Tubercle  bacilli  were  frequently  found 
in  the  mucous  discharges.  A  cavity  could  be  made  out  at  the  left  apex.  The  child 
suffered   with  recurring  pleurisy.      Tlie  chest  contained  a  large  quantity  of  Liquid 


392  DISEASES  OF  THE  PERITONEUM. 

effusion  for  over  four  months.  Nine  ounces  of  a  thin  greenish  fluid  was  aspirated 
from  the  left  side  of  the  thorax.  Examination  showed  tubercle  bacilli  and  also 
streptococci.  The  abdomen  was  enormously  distended  and  a  wave  or  distinct  thrill 
of  liquid  could  be  felt  by  transmitted  palpation.  Extreme  dyspnoea  was  caused  by 
the  pressure  of  this  liquid  on  the  diaphragm.  By  aspiration  I  removed  1000  cubic 
centimeters  of  a  yellowish  serous  liquid  from  the  abdominal  cavity.  Temporary  relief 
was  afTorded,  although  the  abdomen  refilled  very  rapidly.  It  was  necessary  to  tap 
the  same  once  every  six  weeks.  The  child  finally  died  of  exhaustion.  (See  Fig.  118.) 
A  second  case  occurred  in  a  little  girl,  Katie  B.,  about  9  years  old  who  was 
under  the  treatment  of  Dr.  John  H.  Wurthman.  The  same  symptoms  as  I  have 
desci-ibed  in  the  previous  case  were  found,  general  tuberculosis  with  especial  pul- 
monary manifestations  and  symptoms  of  peritonitis.  In  this  case  I  aspirated  over 
three  pints  of  liquid  from  the  abdominal  cavity.  The  child  gradually  sank  and  died 
several  months  later. 

Prognosis. — When  ascites  is  present  the  prognosis  is  not  good,  espe- 
cially if  operative  measures  are  undertaken.     As  a  rule  cases  end  fatally. 

Treatment. — For  a  number  of  years  laparotomy  was  advised  as  the 
best  method  of  treating  tubercular  peritonitis.  Many  successful  cases  were 
reported.  It  was  believed  that  after  the  abdomen  was  opened,  drained,  and 
sunlight  admitted,  that  this  latter  agent  aided  the  healing  process.  In 
recent  years  many  pediatricians  hold  the  opposite  view. 

Light  Treatment. — Not  very  long  ago  I  saw  a  case  of  tubercular  peri- 
tonitis (non-operative)  which  was  progressing  very  nicely.  It  was  under 
the  treatment  of  direct  sun  rays,  besides  receiving  an  electric  light  bath  for 
ten  minutes  each  day.  The  influence  of  light  has  in  recent  years  demon- 
strated its  value,  especially  in  tubercular  manifestations. 

A  very  interesting  monograph  on  this  subject  has  been  published  by 
Aldibert,  of  Paris,  1892.  Baginsky  extols  the  value  of  operative  procedures 
in  tubercular  peritonitis.  The  reader  is  referred  to  modern  works  on  sur- 
gery for  exhaustive  data  on  this  subject. 

The  general  treatment  consists  in  restoratives,  building  up  the  body 
by  nutrition,  and  by  tonics  when  possible. 

Serum  Treatment. — The  use  of  streptolytic  serum  in  doses  of  10  to  30 
cubic  centimeters  is  well  worth  trying.  Antistreptococcus  serum  (10  to 
50  cubic  centimeters)  can  be  injected  in  daily  doses  of  10  cubic  centi- 
meters, or  the  dose  may  be  given  every  two  or  three  days. 

Ascites. 

This  is  an  accumulation  of  clear  serum  in  the  peritoneal  cavity.  When 
it  is  very  severe  there  is,  in  addition  to  the  uniform  distention  of  the 
abdomen,  a  superficial  enlargement  of  the  veins.  This  is  especially  noted 
around  the  veins  of  the  umbilicus. 


ASCITES  DUE  TO  PERITONITIS.  393 

Causes.  —  Pressure  upon  the  vena  cava,  or  chronic  heart  or  lung 
trouble,  such  as  pleurisy,  may  give  rise  to  ascites.  In  extreme  leukaemia, 
anaemia,  or  kidney  disease  ascites  may  be  present. 

Diagnosis. — The  fluid  can  best  be  made  out  by  tapping  the  abdomen 
and  noting  the  transmission  of  the  wave.  On  tapping  the  abdomen  with 
one  hand  and  pressing  the  other  firmly  against  the  opposite  side,  a  wave  of 
fluctuation  can  be  made  out. 

The  symptoms,  prognosis,  and  treatment  will  be  considered  in  the 
article  on  "Ascites  Due  to  Peritonitis." 

Ascites  Due  to  Peritonitis. 

In  the  majority  of  cases  ascites  is  caused  by  tubercular  peritonitis. 
This  condition  resembles  in  its  clinical  and  pathological  aspects  subacute 
or  chronic  pleurisy  with  effusion,  or  subacute  pericarditis. 

Etiology. — No  definite  cause  and  no  specific  agent  has  yet  been  deter- 
mined. Most  of  the  cases  are  associated  with  or  follow  rheumatism,  mea- 
sles, or  exposure  to  cold,  and  in  rare  instances  injury  to  the  affected  parts. 
It  is  also  seen  associated  with  diseases  of  the  kidney,  liver,  and  intestines. 

Pathology. — The  pathological  lesions  are  very  few.  The  effusion  is 
usually  of  a  greenish  color.  In  addition  to  the  serum  there  is  fibrin,  and 
in  some  instances  adhesions.  In  some  cases  all  the  serous  membranes  of 
the  body  seem  to  participate  and  show  evidences  of  inflammatory  condition. 

Symptoms. — The  early  symptoms  of  ascites  consist  of  general  malaise. 
A  child  will  have  a  poor  appetite,  complain  of  headache,  and  sometimes 
constipation.  In  other  cases  diarrhoea  may  exist.  Pain  is  not  present  as 
a  rule.  The  abdominal  distention  comes  on  gradually  and  progresses.  The 
distention  is  usually  the  first  symptom  noted  by  the  mother.  The  fluid 
can  best  be  made  out  by  tapping  the  abdomen  as  described  in  the  foregoing 
article  on  "Ascites."  Fever  is  usually  absent,  although  there  may  be  an 
evening  temperature  of  101°  P. 

Prognosis. — The  prognosis  is  fair  as  a  rule.  I  have  seen  many  cases 
of  ascites  recover,  leaving  no  trace  of  the  former  trouble  behind.  A  cautious 
prognosis  is  advised  if  a  tuberculous  process  is  suspected. 

Treatment. — General  Treatment:  Such  children  must  be  put  to  bed. 
The  diet  should  consist  of  concentrated  liquid  food.  No  solid  meats  should 
be  permitted.  Milk,  if  not  well  borne,  should  be  peptonized  or  fermented. 
Buttermilk  may  be  recommended.  Fresh  air  and  sponge  bathing  should  be 
remembered  as  important  hygienic  factors. 

The  body  should  be  well  protected  to  avoid  chilling  the  surface. 

Treatment  of  the  Ejfnsion. — Small  doses  of  calomel  or  podophyllin 
may  be  given  until  liquid  stools  are  produced.  Diuretics  such  as  cream  of 
tartar,  lemonade,  or  diuretin,  in  5-grain  doses,  will  stimulate  the  action  of 
the  kidneys  and  thus  lessen  indirectly  the  serous  effusion  in  the  abdomen. 


394  DISEASES  OF  THE  PERITONEUM. 

Iodide  of  sodium  in  3  to  lO-grain  doses  should  be  given  three  times  a 
day  to  promote  absorption.  It  may  be  combined  with  iron  in  the  follow- 
ing manner : — 

R  Ferri  et  kali  tartaric 1  drachm 

Sodium  iodide   1  drachm 

Elix.of  lactopeptin,  q.  s.  ad 2  ounces 

Sig. :      One  teaspoonful  three  times  a  day. 

Tapping  the  Abdomen. — Aspirating  the  liquid  by  means  of  a  trochar 
and  cannula  is  a  valuable  means  of  emptying  the  liquid.  It  is  especially 
indicated  if  symptoms  of  dyspnoea  due  to  pressure  on  the  diaphragm  are 
noted. 

If  relapse  occurs  and  the  liquid  continues  to  accumulate  after  several 
aspirations,  then  surgical  treatment  will  be  necessary.  The  occasional  good 
results  seen  in  tubercular  peritonitis  after  a  laparotomy  should  be  remem- 
bered. 


CHAPTEE  VI. 
DISEASES  OF  THE  GENITAL  ORGANS. 

Hernia.^ 

Hernia  is  occasionally  seen  in  the  new-born  baby.  It  is  overlooked 
in  a  good  many  cases  until  the  size  of  the  tumor  indicates  that  something 
is  abnormal,  as  there  are  no  special  symptoms  (see  article  on  "Hygiene  of 
the  Infant"  in  the  "New-born  Infant"). 

"In  congenital  hernia  proper,  anatomical  conditions  favorable  to  vis- 
ceral escape  always  tend  to  permanent  spontaneous  cure  in  infancy  and 
early  childhood.  At  birth  the  spermatic  vessels  are  deeply  covered  by  a 
thick  layer  of  adipose  tissue.  The  dartos  and  cremaster  are  then  highly 
developed,  giving  the  scrotum  dimensions  quite  out  of  proportion  in  size 
to  what  they  are  in  adult  life.  Serous  cysts  of  the  tunica  spermatica  and 
of  the  tunica  vaginalis  being  very  common,  this  condition  also  with  the 
scrotum  fullness  may  simulate  hernia  so  closely  that  it  is  only  by  a  most 
painstaking  examination  we  are  enabled  to  exclude  them.  On  the  other 
hand,  a  small  fringe  of  omentum  may  come  down  with  the  cord  and  be 
completely  overlooked." 

Thomas  II.  Manley,  in  his  monograph  on  "Hernia  and  its  Treatment," 
says :  "The  prevalent  custom  of  applying  a  band  or  binder  around  the 
abdomen  should  be  condemned.  It  conserves  no  useful  purpose;  tlie  only 
excuse  for  it  at  all  is  that  it  retains  the  envelopes  of  the  funis  in  position. 
If  this  firm,  inelastic  compression  does  not  in  many  cases  directly  cause 
hernia  in  those  predisposed  to  it,  I  am  confident  it  often  very  seriously 
interferes  with  spontaneous  cure,  by  the  increasing  pressure  which  it  pro- 
duces against  the  abdominal  walls.  In  the  herniated  infant  tins,  then, 
should  be  cast  aside,  the  dressing  for  the  navel  string  being  held  in  position 
by  adhesive  straps  or  tapes  passed  around  the  body.  After  the  desiccated 
remnant  of  the  cord  has  dropped  off  nothing  whatever  in  the  way  of  a 
girth  should  be  worn  around  the  abdomen,  but  the  garments,  when  the 
erect  attitude  is  taken,  should  be  all  carried  from  the  shoulders,  thereby 
the  feeblest  possible  action  being  given  to  the  diaphragm  and  the  organs 
of  digestion.  Occasionally  we  see  one  side  of  the  scrotum  occupied  by  a 
hernia  before  the  testicle  has  descended.  Congenital  hernia  is  very  rare 
in  females.     In  the  female  the  umbilical  hernia  is  more  common." 

Causes. — A  calculus  in  any  portion  of  the  urethra  or  a  phimosis  or 
atresia  of  the  urethral  canal  may  cause  powerful  contractions  of  the  ab- 


'  For  Umbilical  Hernia  see  chapter  on  "Diseases  of  the  Intestines." 

(395) 


396  DISEASES  OF  THE  GENITAL  ORGANS. 

dorainal  muscles,  resulting  in  a  hernia.  Coughing,  especially  whooping- 
cough,  frequently  produces  hernia.  Constant  straining  efforts  during  con- 
stipation or  when  diarrhoea  persists  frequently  end  in  hernia. 

Symptoms. — In  male  infants  a  tumor  that  is  soft  and  round  will  be 
found  in  the  scrotum.  The  testicle,  although  at  times  difficult  to  feel,  is 
usually  felt  above  or  behind  the  swelling.  This  swelling  consists  of  a  loop 
of  intestine,  rarely  the  peritoneum  descends  with  it.  By  placing  the  child 
on  its  back  the  swelling  can  easily  be  pushed  into  the  abdomen  through  the 
abdominal  ring.  There  is  always  a  gurgling  sound  which  is  characteristic 
of  hernia. 

Diagnosis. — Hernia  is  frequently  mistaken  for  hydrocele.  Both  hy- 
drocele and  hernia  are  sometimes  found  in  the  same  case.  The  following 
differential  points  are  well  worth  noting: — 

Table  No.  59. 
Hydrocele.  Hernia 

1.  Translucent  by  transmitted  light.  1.  Is  opaque. 

2.  Alwaj's  dull  on  percussion.  2.  Always  resonant. 

3.  When  reduction  is  possible  the  fluid        3.  The  hernia  passes  back  quickly  and 

passes    back    slowly    and    noise-  gives   the   characteristic   gurgling 

lessly.  sound. 

4.  No  impulse  on  coughing.  4.  An  impulse  can  be  felt  when  patient 

coughs. 

5.  The  ring  is  empty.  5.  The  ring  is  filled  with  the  neck  of 

the  tumor. 

Prognosis.— This  is  usually  good.  Children  rarely  have  strangulation 
as  we  find  it  in  adults.  Most  of  the  cases  of  hernia  seen  by  me  in  children, 
recovered  with  the  aid  of  a  properly  fitting  truss.  At  times  nothing  but  an 
operation  Avill  cure  the  case. 

Treatment. — The  diet  should  be  regulated.  If  any  apparent  cause 
exists,  such  as  prolonged  diarrhoeas  with  tenesmus,  constipation,  or  cough, 
the  same  should  be  treated.  If  a  whooping-cough  exists  the  proper  treat- 
ment must  be  instituted  before  mechanical  appliance  is  ordered.  This 
consists  chiefly  in  relieving  the  hernia  with  a  truss.  My  own  experience 
has  been  rather  good  by  having  a  rubber  sponge  with  a  rough  surface  made 
to  include  the  hernia.  This  should  be  held  in  place  by  the  usual  strap 
going  around  the  body.  The  leather  covered,  or  the  celluloid  front  pads 
are  continually  slipping;  hence,  not  so  well  adapted  for  children.  The 
hygiene  should  be  well  considered  in  a  child.  A  truss  on  a  diapered  infant 
is  a  nuisance,  it  cannot  be  kept  clean;  hence  every  nurse  or  mother  should 
be  instructed  regarding  the  sensitive  skin  and  the  danger  of  causing  irri- 
tation from  moisture.  Every  mother  should  be  taught  to  watch  the  infant 
when  it  cries  or  strains  to  prevent  the  truss  from  slipping. 


PHIMOSIS.  397 

Surgical  Treatment. — With  modem  aseptic  methods  there  is  little 
or  no  risk  in  an  operation.  The  success  of  the  Bassini  operation  is  so 
uniform  that  I  have  seen  dozens  of  children  operated  with  no  fatalities. 
For  the  details  of  this  surgical  method  I  would  refer  the  reader  to  text- 
books on  surgery. 

Hydrocele. 

"The  testicle  in  its  descent  is  surrounded  by  a  serous  membrane 
described  by  some  authors  as  a  serous  pouch.  When  this  pouch  fills  with 
serum  it  is  called  a  hydrocele.  Xormally  a  few  drops  of  serum  are  found 
in  the  tunica  vaginalis  propria.  Larger  accumulations  are  met  with  in 
more  than  10  per  cent,  of  male  infants,  mostly  on  the  right  side,  seldom 
en  both.  In  the  majority  of  cases  there  is  no  longer  a  communication 
^ith  the  abdominal  cavity.  When  it  remains  a  hernia  may  complicate 
the  hydrocele  and  the  diagnosis  be  more  diificult,  because  the  fluid  is  apt  to 
return  occasionally  into  the  abdomen.  Spontaneous  absorption  is  not  very 
rare,  but  suppuration  is  uncommon." 

Treatment. — Under  aseptic  precautions  a  sterilized  needle  or  trocar 
should  be  introduced.  By  this  means  the  serum  can  be  removed.  This 
pimple  method  has  frequently  resulted  in  a  cure.  When  the  hydrocele  fills 
up  again  the  injection  of  a  few  drops  of  tincture  of  iodine  or  Lugol's  solu- 
tion, or  pure  carbolic  acid  after  the  serum  has  been  withdrawn,  will  usually 
prove  successful.  Operations  are  rarely  required,  although  they  are  indi- 
cated if  this  milder  form  of  treatment  proves  unsuccessful. 

Adherent  Prepuce. 

Congenital  agglutination  of  the  prepuce  and  the  glans  penis  is  occa- 
sionally reported.  The  majority  of  cases  seen  are  acquired  conditions. 
Smegma  frequently  collects  under  the  foreskin  when  the  same  is  not  prop- 
erly cleaned. 

Treatment. — With  a  blunt  probe  an  adherent  prepuce  can  be  loosened 
from  the  glans  penis.  The  smegma  should  be  removed  and  the  parts 
lubricated  with  albolene  or  olive-oil.  The  mother  or  nurse  should  be 
instructed  to  oil  these  parts  and  thoroughly  separate  the  prepuce  so  that 
new  adhesions  do  not  form.  If  this  trouble  recurs  then  circumcision  is 
indicated. 

Phimosis. 

Phimosis  is  due  to  a  narrowing  or  contraction  of  the  prepuce  so 
that  the  foreskin  is  prevented  from  being  drawTi  back  over  the  glans 
penis.  A  tight  prepuce  or  an  elongated  prepuce  is  a  constant  source  of 
irritation.  Bed  wetting  is  a  very  frequent  symptom  of  this  condition. 
There  is  an  itching  and  an  irritation  which  frequently  leads  to  bad  habits. 
The  sensitive  condition  sometimes  causes  priapism,  and  this  may  lead  to 


398  DISEASES  OF  THE  GENITAL  ORGANS. 

masturbation.  Night  terrors  and  insomnia  are  frequently  caused  by  this 
condition.  Phimosis  is  sometimes  an  exciting  cause  of  chorea  and  various 
nervous  diseases. 

Symptoms. — Such  children  invariably  suffer  with  anaemia.  They  are 
peevish  and  restless  and  constantly  irritable.  The  main  symptoms  are  a 
series  of  irritations  caused  by  the  tight  foreskin  as  outlined  above.  In 
exceptional  instances  strong  healthy  children  may  not  show  any  symptoms 
of  this  condition. 

The  following  case  was  seen  by  me  in  private  practice: — 

A  boy,  4  years  old,  has  always  been  in  apparently  good  heaJth.  He  was 
breast-fed,  well-nourished,  and  showed  no  evidence  of  rickets.  His  mother  com- 
plained to  me  that  the  child  had  a  "weak  bladder,''  that  he  could  not  hold  his  urine, 
especially  at  night.  He  was  restless  and  peevish,  and  tossed  about  in  his  sleep. 
On  examination  I  found  a  phimosis  existed.  The  prepuce  did  not  slip  over  the 
glans  and  the  child  cried  as  though  in  pain  whenever  the  genitals  were  touched. 
I  ad-vised  stretching  the  foreskin  and  this  was  done  every  few  days  with  some  degree 
of  success,  for  the  period  of  about  three  months.  The  child  improved.  When  seen 
again  about  one  year  later  the  symptoms  of  nervousness,  and  restlessness  reappeared. 
I  then  advised  circumcision.  With  the  assistance  of  Dr.  John  H.  Wurthman,  who 
administered  chlorofonn,  the  prepuce  was  removed,  the  parts  were  dusted  with 
europhen  and  the  woimd  healed  per  primam.  The  child  iinproved  gradually  and  is  a 
good  healthy  child  to-day. 

Treatment. — The  treatment  outlined  in  the  case  above  described  is  the 
only  one  that  should  be  used :  First,  stretching  the  prepuce,  and  secondly, 
if  this  does  not  afford  relief,  circumcision. 

Operation. — A  pimple  method  is  to  make  an  incision  or  cut  the  dorsum 
of  the  prepuce  with  a  scissors.  After  this  incision  is  made  we  invariably 
have  another  skin  to  divide  which  is  the  mucous  membrane.  Unless  this 
is  also  incised  we  cannot  expect  relief  from  the  constriction.  As  a  rule  small, 
cheese-like  particles,  called  smegma,  will  be  found  which  must  be  cleaned 
away.  Then  follows  the  surgical  treatment,  such  as  checking  haemorrhage, 
if  the  same  is  profuse.  In  rare  cases  one  or  more  stitches  may  be  necessary 
to  control  the  bleeding.  I  invariably  use  a  piece  of  sterile  gauze  saturated 
with  Monsel's  solution  immediately  after  the  operation,  then  dust  the  parts 
with  europhen.  Great  care  should  be  used  to  avoid  infection  from  a  case 
of  diphtheria  or  erysipelas.  It  is  safer  to  have  a  surgeon  supervise  or  per- 
form the  operation  than  to  run  the  risk  of  infection. 

Paraphimosis. 

This  is  a  condition  caused  by  the  swelling  of  tbe  glans  or  by  an  abnor- 
mally small  preputial  orifice. 

Treatment. — Have  the  thumb  and  finger  of  one  hand  pressing  on  the 
glans,  with  the  other  hand  an  attempt  should  be  made  to  draw  the  prepuce 


CRYPTORCHIDISM.  399 

back  in  position.  In  some  cases  immersing  the  parts  in  very  warm  water 
for  several  minutes  has  served  me  very  well.  If  the  parts  are  very  tender 
a  spray  of  ethyl  chloride  can  be  used  with  advantage  before  the  attempted 
reduction.  When  the  parts  are  very  oedematous  then  puncturing  the  sur- 
face to  relieve  the  serum  will  sometimes  yield  good  results.  At  times  sur- 
gical relief  may  be  demanded. 

Hypospadias. 

The  urethra  sometimes  opens  on  the  under  side  of  the  penis.  This  is 
always  a  congenital  condition. 

A  case  of  this  kind  was  seen  by  me  in  consultation  with  Dr.  Julius  Brandeis,  of 
New  York  City.  When  I  saw  this  infant  it  was  three  days  old  and  apparently 
suffering  pain.  The  bladder  was  distended  and  the  infant  had  not  urinated, 
according  to  the  history  given,  since  it  was  born.  An  examination  showed  a 
hypospadias.  The  urethral  orifice  in  the  glans  penis  was  absent.  With  tlie  aid 
of  diuretics  and  a  warm  hip  bath  the  infant  urinated.  I  have  seen  this  child  many 
times  since.     He  is  now  able  to  walk  and  talk  and  suffers  no  inconvenience. 

The  treatment  is  radical — by  means  of  plastic  surgery. 

Epispadias. 

In  this  condition  the  opening  of  the  urethra  is  on  the  superior  surface 
of  the  penis.     It  is  less  frequently  met  with  than  hypospadias. 

The  treatment  is  distinctly  surgical  and  requires  a  plastic  operation. 

Cryptorchidism   (Undescended  Testicle). 

The  testes  usually  descend  into  the  scrotum  during  the  ninth  month 
of  pregnancy.  In  some  children  the  testicles  may  remain  in  the  inguinal 
canal  or  even  in  the  abdomen. 

Ralph  C.  was  referred  to  me  by  Dr.  W.  Freudenthal.  He  was  a  well-nourished, 
healthy  child.  Was  breast-fed  and  in  apparent  good  health  until  two  years  ago. 
He  suffered  with  cough,  was  a  mouth  breather,  and  snored  at  night,  for  the  relief 
of  which  Dr.  Freudenthal  removed  his  adenoids.  The  child  was  brought  to  me  for 
the  relief  of  an  irritable  and  restless  condition.  His  mother  stated  that  he  scratched 
his  nose  and  appeared  to  have  a  pruritis  of  the  anus.  The  diagnosis  of  ascarides 
lumbricoides  was  made.  While  examining  the  child  I  found  one  testicle  could  be 
palpated  in  the  scrotum  and  the  other  in  the  inguinal  canal.  By  pressure  on  the 
abdomen  it  would  descend.  There  were  no  symptoms  directly  attributable  to  this 
condition. 

Treatment. — If  no  irritation  is  caused  then  let  it  alone.  If  a  false 
passage  has  been  made  which  gives  rise  to  pain,  then  the  question  of 
removal  of  the  testicle  may  come  up.    The  case  then  is  distinctly  surgical. 


400  DISEASES  OF  THE  UE>;iTAL  ORGANS. 

OliCIlITIS. 

An  iiifiannnaliuu  of  the  testicle  is  a  rare  eoinlitiou  iu  infancy.  Cases 
have  been  reported  where  injury  caused  orchitis,  hi  tlie  article  on  "Munips" 
orcliitis  is  mentioned  as  a  complication.  Tlir  nxalnieiit  consists  in  rest  and 
ice-cold  applications  of  lead  and  opium.  Laxatives  are  indicated  to  open 
the  bowels  and  thus  help  relieve  the  inflammation. 

Uketiikitis :    Vllvo-vaginitis. 

Vulvo-vaginitis  is  a  catarrhal  infectious  disease  involviii^i^  tlie  female 
genital  tract.    It  is  divided  into: — 

(«)    Simple  or  Catarrhal;  (h)   Gouorrhceal. 

Simple  Vaginitis, 

The  normal  urethra  of  both  male  and  female  children,  also  the  vagina, 
frequently  has  a  simple  catarrh.  The  symptoms  noticed  are  those  of  swell- 
ing, inflammation  and  a  catarrhal  secretion. 

Etiology  and  Bacteriology. — Normally  the  vagina  contains  a  wdiitc 
diplococcus  which  is  not  decolorized  by  Gram. 

In  simple  catarrhal  vulvo-vaginitis  we  have  a  white  diplococcus  which 
also  is  not  decolorized  by  Gram. 

In  gonot"rha>al  vulvo-vaginitis  we  have  a  Avhite  diplococcus  which  docs 
not  decolorize  by  Gram,  and  in  addition  thereto  a  yellow  diplococcus  called 
D.  Flavus  (Bumm). 

These  germs  are  usually  found  in  conjunction  with  other  micro-organ- 
isms or  with  streptococci.  They  easily  stain  with  a  watery  solution  of  eosin 
and  counterstain  with  an  alkaline  acpieous  methylene  l)lue  solution. 

The  microscopical  examination  shows  leucocytes,  epithelium,  and 
various  micro-organisms;  never  gonococci. 

Symptoms. — The  ])arts  are  usually  sensitive  to  pressure. 

Children  who  are  old  enough  complain  of  pain  on  urination,  and  also 
urinate  very  frequently.  Tn  very  young  children  it  is  impossible,  in  fact, 
unnecessary,  to  make  a  vaginal  or  uterine  examination. 

This  disease  may  last  for  months,  especially  so  if  the  body  is  in  a 
subnormal  condition. 

This  sim])le  catairh  aff'ectijig  the  vulvo-vagina  is  highly  contagious, 
hence  each  case  .should  he  strictly  isolated. 

Children  so  afflicted  should  sleep  alone. 

Goxoi;i!iia':AL  Vaoinitis. 

Gonorrhoea!  vulvo-vaginitis  is  fre(|uently  met  with  in  practice.  As  a 
rule  it  occurs  among  poorer  classes  where  families  are  ci'owded  and  un- 
sanitary.    Frequently  the  infection    is  transmitted   from  the  adult  to  the 


GONORRIiCEAL  VAGINITIS.  401 

child  by  sleeping  in  an  infected  bed.  Cases  are  on  record  where  a  mother 
suffering  with  gonorrhoeal  vulvo-vaginitis  has  infected  her  child  while 
sleeping  with  it. 

Etiology. — The  slightest  abrasion  of  the  skin  will  permit  the  entrance 
of  the  goDococcus.  Cases  have  been  reported  in  which  a  healthy  person  was 
infected  by  taking  a  bath  in  the  same  tub  in  which  a  person  affected  with 
gonorrhoea  had  bathed  the  day  previous.  It  is  a  well-known  fact  that  the 
gonococcus  will  live  twenty-four  hours,  hence  these  germs  will  persist  in  the 
tub  and  can  transmit  infection.  For  this  reason  a  separate  tub  should 
be  procured  while  gonorrhoeal  disease  exists. 

Bacteriology. — Gonorrhoeal  vaginitis  is  caused  by  the  presence  of  the 
gonococcus.  It  is  necessary,  however,  to  subject  the  gonococcus  described 
by  Neisser  to  the  Gram  method  of  staining.  The  diplococcus  found  in  the 
normal  urethra  can  easily  be  differentiated  by  subjecting  the  same  to  the 
Gram  stain.  Xormally  the  gonococcus  has  never  been  found  in  the  vulvo- 
vaginal tract  or  in  the  normal  urethra.  The  gonococcus  can  easily  be 
stained  with  a  2  per  cent,  alcoholic  methylene  blue  solution. 

Mode  of  Infection. — Direct  transmission  of  infected  matter  from  adults 
to  children  has  been  known  to  occur.  Infected  clothing,  especially  bed 
linen,  has  transmitted  this  disease. 

In  rare  instances  the  infection  has  taken  place  directly  during  the 
sexual  act.  There  is  a  popular  superstition  that  when  an  adult  male  has 
gonorrhoea  he  will  be  cured  by  raping  a  healthy  child.  An  instance  of  this 
kind  has  occurred  in  my  practice. 


Fig.  110. — Gonococcus.  (Gonorrhoeal  Pus.)  Stained  one-lialf  minute 
with  methylene-blue.  a,  Free  in  groups.  6,  Enclosed  in  pus  cells.  Leitz 
ocular  I.     Oil  imcrsion  Vi2-      ( Lenhartz-Brooks. ) 


402  DISEASES  OF  THE  GENITAL  ORGANS. 

A  little  girl,  6  years  old,  apparently  healthy,  was  infected  by  an  adult  suffering 
with  gonorrhoea.  She  suffered  continuously  for  over  four  months  until  brought  to 
me,  when  her  vulva,  vagina,  and  urethra  were  one  mass  of  inflammation.  There 
was  a  greenish  yellow  discharge.  The  bacteriological  examination  showed  diplococci 
in  the  leucocytes. 

The  child  was  put  to  bed  and  a  sterilized  pad  applied  over  the  genitals.  This 
pad  was  changed  every  four  hours.  A  sitz  bath  of  1  to  2000  warm  bichloride  was 
ordered  morning  and  evening,  lasting  twenty  minutes.  A  vaginal  injection  of  5  per 
cent,  argyrol  solution  was  given  immediately  after  each  bath.  Internally  iron 
was  given.  The  discharge  continued  eleven  days  and  everything  seemed  well.  A 
reinfection  evidently  took  place  iowr  days  after  having  stopped  the  active  treatment, 
as  the  discharge  appeared  with  renewed  vigor.  The  child  was  again  carefully 
treated  with  astringents.  The  discharge  persisted  for  three  months,  when  it  was 
finally  cured. 

Complications. — The  Eye:  The  clanger  of  transmitting  gonorrhceal 
infection  by  the  hands  from  the  genitals  to  the  eyes  must  always  be  re- 
membered. That  this  form  of  infection  is  not  without  danger  is  well 
known.  At  the  Eiverside  Hospital  in  the  scarlet  fever  wards,  during  the 
STunmer  of  1902, 1  saw  a  child  that  was  totally  blind,  the  result  of  a  gonor- 
rhceal infection. 

The  Joint. — We  occasionally  meet  with  symptoms  of  inflammation 
involving  one  large  joint;  this  is  called  monarthritis.  An  inflammation 
of  this  kind  usually  means  gonorrhceal  infection. 

The  Heart. — When  the  gonococcus  enters  the  circulation  it  frequently 
attacks  the  valves  of  the  heart.  Valvular  lesions  are  similar  to  joint  lesions, 
hence  we  must  not  be  surprised  to  see  cases  reported  in  which  a  gonorrhoea 
started  at  the  genital  tract,  entered  the  circulation,  and  involved  the  heart. 
A  case  of  this  kind  was  reported  by  Leyden,  of  Berlin. 

Pyelitis  caused  by  an  extension  of  this  infection  from  the  urethra  may 
end  fatally.  An  infection  may  spread  from  the  vagina  into  the  uterus  and 
set  up  a  salpingitis  and  end  fatally.  On  the  other  hand  this  disease,  if 
neglected,  may  assume  a  chronic  tendency  and  cause  sterility,  so  that  a 
guarded  prognosis  should  be  given  in  every  case  until  the  infection  is  modi- 
fied and  the  outlook  is  good.     (Eead  article  on  "Pyelitis.") 

VULVO-VAGINITIS   FOLLOWING    SCARLET   FeVER. 

At  the  Eiverside  Hospital  during  the  summer  of  1903,  out  of  100  cases 
of  scarlet  fever  there  were  15  cases  suffering  with  vulvo-vaginitis.  In  these 
there  was  a  well-marked  purulent  discharge  upon  the  deeper  parts  of  the 
vulva  and  at  the  vaginal  opening,  with  some  redness  and  irritation.  With 
this  there  was  a  distinct  rise  of  temperature  and  some  constitutional  distur- 
bance. The  cases  all  yielded  promptly  to  treatment,  proving  especially 
amenable  to  simple  astringent  solutions  rather  than  to  more  active  ger- 
micides.^ 


*  Reported  to  me  by  Dr.  G.  L.  Nicholas,.  Resident  Physician. 


\  TLVO-VAGTXITIS  FOLL()\\IN(^   SCARLET  FE\ER.  403 

]t  is  not  imcommon  to  find  cases  of  vulvitis  and  also  vaginitis  occ-urring 
in  the  scarlet- fever  wards  for  which  there  is  no  adequate  explanation. 

Aailvo-vaginitis  as  seen  at  the  Riverside  Hospital  occurs  as  a  distinct 
complication  to  scarlet  fever.  When  it  occurs  it  shows  a  distinct  rise  of 
temperature  and  also  a  peculiar  constitutional  disturbance.  ^Yhen  this 
is  contrasted  with  the  symptoms  of  a  catarrhal  otitis  the  similarity  of  both 
conditions  must  be  apparent.  Not  only  do  we  have  similar  bacteriological 
findings,  but  the  infection  manifests  itself  in  a  rise  of  temperature  and 
general  s^'stematic  disturbance. 

AMiile  an  occasional  case  of  true  gonorrheal  disease  may  arise  in 
which  the  Xeisser  gonococcus  will  be  found,  from  a  large  clinical  experience 
in  both  hospital  and  private  practice,  I  must  say  that  such  cases  are  very 
exceptional. 

Prognosis. — The  prognosis  is  iisually  good,  although  we  must  bear  in 
mind  that  if  these  cases  are  neglected  serious  results  may  follow.  Infection 
may  spread  from  the  urethra  into  the  bladder  and  from  the  bladder  into 
the  ureters,  and  infect  the  kidneys. 

Treatment. — Hygienic  Treatment. — In  this  disease  more  than  in  any 
other  the  strictest  attention  to  hygienic  rules  is  demanded.  If  it  is  an 
infant  that  is  %o  afflicted,  the  pads  should  thoroughly  cover  the  vulva  and 
be  saturated  with  a  weak  solution  of  bichloride.  This  pad  should  be  ad- 
justed with  the  aid  of  a  T-l)iiidor.  If  there  is  severe  itching  from  excoria- 
tion and  the  child  has  a  tendency  to  scratch,  the  hands  should  be  guarded 
so  that  the  infection  cannot  be  carried  from  the  genital  tract  to  the  eyes. 

Local  Treatment. — Labarraque's  solution  is  a  very  valual)le  remedy. 
It  may  be  used  in  a  5  per  cent,  solution.  My  plan  has  been  to  add  about 
1  ounce  of  chlorine  M'ater  to  1  pint  of  lukewarm  water  and  irrigate  morn- 
ing and  evening,  noting  the  effect.  If  the  discharge  is  not  lessened  thereby, 
the  injection  should  l)e  given  three  times  a  day. 

Astringent  solutions,  such  as  sulpho-carbolate  of  zinc,  sulphate  of  zinc, 
or  sulphate  of  copper^  using  1  grain  to  the  ounce,  are  useful.  When  there 
is  intense  itching  it  is  a  wise  plan  to  instill  a  2  per  cent,  ichthyol  glycerine 
solution  into  the  vagina  after  the  same  has  been  thoroughly  washed  witli 
one  of  the  above  astringent  solutions. 

Argyrol,  25  ])er  cent,  solution,  has  been  used  as  an  injection  several 
times  a  day  with  remarkable  success  at  the  Willard  Parker  Hospital  by 
l)r.  Stiiddiford. 

Tlie  persistence  of  vulvo-vaginitis  in  spite  of  the  local  methods  of 
treatment  has  h'd  to  the  trial  of  a  new  I'orm  of  treatment.  From  the  growth 
of  bacteria  taken  t'l'om  the  vaginal  discharge,  injections  of  an  emulsion  of 
50,()0(),0()()  bacteria  were  given  hypodermically.  Such  injections  were 
repeated  once  daily.  The  dose  was  increased  to  <i()  and  70,000,000  bacteria. 
These  injections  used  at  the  Willy  id  Tarker  Hospital  have  proven  very  sue- 


404  DISEASES  OF  THE  GENITAL  ORGANS. 

cessful  and  may  open  a  new  form  of  treatment.  Cultures  ji'rown  were  nuule 
nnder  the  supervision  of  Dr.  Wni.  H.  I'ai'k  in  charge  of  the  Eeseareli 
Laboratory. 

Constilutiumd  Treatment. — Iron  and  codliver-oil  sliouUl  be  given  for 
several  months  as  a  restorative.  Persistent  h)cal  treatment  alone  is  fre- 
quently of  no  avail,  and  T  have  noticed  that  this  condition  persists  nntil 
iron,  arsenic,  or  other  similar  tonics  are  given  internally.  The  value  of 
nutrition  must  not  be  underestimated. 

Vicarious   jMexstkuatiox, 

Some  children  have  a  periodical  nose  bleed  recurring  every  three  or    | 
four  weeks.     In  some  cases  there  is  a  considerable  flow  of  blood  lasting    ' 
between  two  and  five  days.     In  nudving  the  diagnosis  it  is  important  to 
e.xclude  all  diseases  due  to  local  causes,  such  as  polypus  or  haMuophilia. 
In  one  case  seen  by  me    (see  chapter  on  ''Syphilis")    fatal  hi^morrhage 
resulted  in  a  case  of  congenital  syphilis. 

The  cause  is  unknown. 

Treatment. — The  body  should  he  strengthened  and  iron  given  inter-  j 
nally.  A  change  of  air  to  the  seashore  or  moimtains  will  strengihen  the  ' 
body  and  frequently  relieve  this  condition. 

Menstruation   Pr.ecox. 

We  occasionally  see  girls  from  G  to  10  years  of  age  with  regular  men- 
struation. Literature  records  numerous  cases  of  children  from  2  to  5  3'ears 
of  age  with  regular  recurring  menstruation.  Such  menstruation  lasts  sev- 
eral days  or  in  some  instances  several  hours.  As  a  rule  such  children  are 
delicate,  tuberculous,  or  syphilitic. 

Symptoms. — There  is  usually  pain  in  the  abdoiuen  similar  to  colic, 
restlessness,  and  a  series  of  nervous  symptoms.  Such  children  are  hard 
to  please. 

Diagnosis. — It  is  necessary  to  exclude  local  causes,  such  as  papillo- 
nuitous  or  polypoid  excrescences.  I  have  previously  referred  to  haemophilia 
and  to  syphilis  as  a  possible  cause.  Local  causes,  such  as  masturbation  or 
traumatism,  must  be  excluded.  As  a  sequela  to  acute  infectious  diseases, 
we  frequently  have  vaginal  catarrh.  This  discharge  may  sometimes  be 
mixed  with  blood.  The  diagnosis  depends  on  the  regularity  of  the  periods 
recurring  every  three  or  four  weeks. 

Treatment. — Warm  demulcent  drinks  and  the  avoidance  of  cooling 
liquids.     The  child  should  be  kept  in  bed  and  warmly  dressed. 

If  the  Ijleeding  is  very  profuse  then  5  to  10  drops  of  fluid  extract  of 
ergot  (Squibb's),  or  hydrastinin  hydrochloratc,  Vio  +"  V-jo  grain,  three 
times  a  day,  may  l)e  given.  An  ice-bag  over  the  abdomen  will  frequently 
relieve  severe  pain  and  cheek  profuse  bleeding. 


CHAPTER  VII. 

DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

The  Kidney.^ 

The  kidneys  of  an  infant  are  proportionately  larger  than  in  adult  life. 
They  are  also  situated  lower  than  in  the  adult.  The  large  size  of  the  liver 
in  infancy  is  the  reason  for  the  difference  in  position  of  the  right  and  left 
kidney.  The  right  kidney  is  situated  lower  than  the  left.  The  suprarenal 
capsules  are  much  larger  than  in  the  adult.  After  the  second  year  the 
kidneys  assume  the  position  usually  occupied  by  the  adult  kidneys. 

Acute  Nephritis  (Acute  Glomerulo-Nephritis  :  Acutb 
Bright's  Disease). 

Primary  nephritis  is  by  no  means  a  rare  condition  in  childen.  In 
the  majority  of  text-books  nephritis  is  described  as  the  complication  of 
infectious  diseases.  It  is  true  that  it  is  most  often  seen  following  the 
acute  infectious  diseases.  In  primary  nephritis  the  source  of  infection  is 
sometimes  hard  to  trace.  Pathogenic  bacteria  can  reach  the  kidneys 
through  the  circulation  and  thus  set  up  nephritis. 

Etiology. — The  influence  of  exposure,  "taking  cold,"  must  be  looked 
upon  as  an  associated  factor  in  the  causation  of  this  disease. 

Comby  ^  explains  this  as  follows : — 

In  the  absence  of  a  specific  process,  such  as  scarlatina,  diphtheria,  etc., 
we  are  led,  upon  the  occurrence  of  acute  simple  nephritis,  to  suspect  the 
influence  of  cold.  The  action  of  cold,  however,  is  not  always  direct.  In 
nephritis,  as  in  pneumonia,  cold  alone  does  not  cause  the  disease.  It  en- 
feebles the  organism,  increases  its  receptivity,  augments  the  virulence  of 
•microbes,  and  opens  the  gates  by  which  they  enter.  Children  carry  within 
themselves,  in  the  mouth,  pharynx,  and  nasal  passages,  various  microbes 
which  only  await  an  opportunity  of  wakening  into  activity.  This  opportu- 
nity is  afforded  them  by  the  impression  of  cold. 

The  sore  throat  which  so  often  precedes  nephritis  constitutes  a  first 
step  toward  the  invasion  by  pathogenic  microbes.  The  epithelial  barrier 
is  broken  down,  the  micro-organisms  reach  the  lymphatic  glands,  where 
they  are  often  arrested  or  may  continue  their  progress,  passing  into  the 

'The  urine,  its  physiological  and  pathological  condition,  is  described  in  detail 
in  the  chapter  on  "Urine,"  Part  XII. 

'  "Nephrite  Aigue  Simple  dea  Enfants,"  par  le  Dr.  J.  Comby,  La  M6decine 
Modeme,  December  1,  1897. 

(405) 


406  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

circulation,  and  finally  excite  a  distant  inflammation  which  may  be,  accord- 
ing to  circumstances,  a  pneumonia,  an  endocarditis,  or  nephritis,  etc. 

In  some  cases  an  apparently  most  trivial  angina  becomes  complicated 
with  swollen  cervical  glands,  and,  subsequently,  with  acute  nephritis,  etc. 
Cases  have  been  described  as  glandular  fever,  or,  in  other  words,  acute 
adenitis,  symptomatic  of  pharyngeal  infection,  in  which  nephritis  has 
developed,  superadded  to  the  original  disease,  which  it  finally  survives. 
These  complications  are  not  fortuitous,  but  are  linked  together  in  strict 
sequence. 

Pathology. — Inflammation  of  the  kidney  in  a  large  majority  of  cases 
commences  as  a  glomerulo-nephritis,  the  delicate  walls  of  the  capillaries, 
and  their  equally  delicate  epithelial  investment  being  the  earliest  to  suffer; 
and  instead  of  the  non-albuminous  urine,  one  laden  with  albumin  escapes. 
If  the  inflammation  still  progresses,  corpuscles,  especially  the  red,  make 
their  way  out  and  produce  smoky  or  bloody  urine,  the  naturally  high  pres- 
sure in  the  glomerulus  no  doubt  greatly  facilitating  the  diapedesis.  The 
casts  which  may  now  appear  consist  for  the  most  part  of  fibrin,  of  red  and 
white  corpuscles,  and  of  renal  debris,  moulded  in  the  tubes. 

The  glomerular  disturbance  is  followed  by  that  of  the  rest  of  the  vas- 
cular net-work  and  of  the  gland  cells.  The  latter  become  swollen  and 
"clouded,"  and  are  readily  detached.  The  swollen  cells  may  occlude  the 
lumen  of  the  ducts  and  press  upon  the  vascular  tissue  without.  Or  the 
capillaries  are  congested  and  exudation  swells  the  intertubular  tissue.  In 
any  case  the  tissue  is  enlarged  and  softened.  Sometimes  during  life  the 
signs  of  nephritis  are  well  marked,  but  after  death  the  anatomical  lesion 
appears  very  slight;  in  these  cases  comparison  with  a  normal  kidney,  both 
to  the  naked  eye  and  under  the  microscope,  is  invaluable,  as  then  some 
change  can  usually  be  detected. 

The  kidney  of  typhoid  and  diphtheria  serve  as  examples,  although 
there  are  numerous  acute  specific  diseases  which  are  accompanied  by  ne- 
phritis and  albuminuria.  The  glomeruli  are  enlarged,  owing  to  swelling 
of  the  interstitial  substance  and  to  engorgement  of  the  capillaries  and. 
often  swelling  of  the  endothelial  cells;  there  is  in  addition  an  increase 
in  the  number  of  nuclei  in  the  glomeruli.  Bowman's  capsules  may  be 
slightly  distended,  their  endothelium  swollen  or  proliferating,  and  the 
spaces  occupied  by  fibrin  or  white  or  red  corpuscles.  There  may  be  an 
increase  in  corpuscles  around  the  roots  of  the  glomeruli.  The  tubules  may 
be  dilated,  the  epithelium  swollen  and  granular,  or  there  may  be  some 
proliferation.  Casts  are  numerous,  though  usually  hyaline;  they  may 
consist  of  blood.  Small  haemorrhages  are  frequent,  especially  in  diph- 
theritic kidneys. 

Acute  nephritis  in  the  new-born  has  been  described  by  Jacobi.* 


'  New  York  Medical  Journal,  January,  1896. 


ACUTE  AEPHRITIS.  407 

Symptoms. — Gastric  clisturljances,  such  as  vomiting,  are  very  fre- 
quently noted.  As  a  rule  premonitory  symptoms  are  absent.  Xephritis  fre- 
quently begins  with  fever,  loss  of  appetite,  headache,  and  general  malaise. 
Swelling  of  the  face  is  sometimes  the  first  sign  of  trouble. 

The  urine  is  always  scanty  and  sometimes  contains  red  blood-corpus- 
cles, leucocytes,  and  casts.  The  urine  shows  the  evidence  of  acute  renal 
congestion  and  is  always  albuminous.  In  grave  cases  there  are  frequent 
efforts  to  2)ass  urine,  and  these  attempts  are  attended  with  pain.  With  great 
difficulty  the  child  expels  a  few  droj^s  of  dark  colored  urine.  According 
to  the  severity  of  the  case  these  symptoms  subside  after  a  period  varying 
from  ten  to  thirty  days.  Irregularity  of  the  pulse  is  frequently  noted,  and 
should  always  be  looked  uj)on  as  an  evidence  of  toxsemia.  It  is  a  grave 
symptom. 


Fig.    120. — Nepliritis   Complicating  Diphtheria.     Case  seen  by  me 
at   the  Willard  Parker  Hospital.      (Original.) 

The  action  of  the  heart  should  l)e  closely  followed  in  every  case  of 
nephritis. 

Prognosis.— This  is  usually  good.  If  treatment  is  neglected  in  an 
acute  nephritis,  a  chronic  nephritis  will  result.  In  rare  instances  a  general 
toxa?mia  nmy  cause  convulsions  and  death. 

Nephritis  a  Complication. — This  disease  may  accompany  or  follow 
scarlet  fever  or  diphtheria.  It  is  also  occasionally  seen  in  most  infectious 
diseases  such  as  typhoid,  measles,  varicella,  pneumonia,  influenza,  malaria, 
meningitis,  and  empyema. 

In  a  study  of  gastro-enteritis  made  by  Baginsky,  the  frequent  asso- 
ciation of  nephritis  was  noted.  This  author  found  that  the  l)acterium  coli 
could  frequently  cause  acute  nephritis. 

Elaine  K.,  a  girl,  ,5  years  old,  had  vomiting,  followed  In'  an  eruption  of  scarlet 
fever  covering  the  entire  body.  The  rash  was  distinct  for  three  days  and  then 
faded.     The  physician  in  attendance  said  it  was  a  case  of  mild  scarlet  fever.     The 


408  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

child  was  up  and  about  during  the  second  week  following  the  eruption.  The  stomach 
was  not  carefully  guarded,  as  the  child  was  given  a  too  liberal  diet.  On  the  twelfth 
day  from  the  beginning  of  her  illness  she  suddenly  had  what  the  family  called  a 
sinking  spell.  Evidences  of  heart  weaJcness  were  noted.  Two  days  later,  or  on 
the  fourteenth  day  of  her  illness,  she  was  again  put  to  bed.  At  this  time  she  com- 
plained of  pains  in  her  joints.  The  glands  of  the  neck  were  swollen.  The  urine 
was  somewhat  scanty.     On  the  seventeenth  day  she  had  three  very  severe  convulsions. 

Owing  to  the  careless  management  of  this  case,  the  family  discharged  the 
first  attending  physician.  Later  the  family  called  Dr.  M.  Pechner,  who  saw  the 
severe  toxaemia  and  noted  the  anuria.  I  saw  this  case  twenty-one  days  after  the 
beginning  of  the  disease,  through  the  kindness  of  Dr.  Pechner.  The  diagnosis  of 
nephritis  was  easily  made.  Hardly  an  ounce  of  urine  was  passed  during  the  day. 
The  child  was  oedematous  and  had  the  waxy  appearance  seen  in  acute  nephritis.  The 
heart  sounds  were  muffled.  The  pulse-rate  was  slow  and  irregular.  The  tempera- 
ture was  very  slightly  elevated,  although  a  severe  myocarditis  existed.  The  child 
was  placed  in  bed,  under  the  care  of  two  trained  nurses. 

Treatment. — Hot  packs,  diaphoretics,  and  diuretin,  in  doses  of  5  to  20  grains, 
three  and  four  times  a  day,  were  given.  Hot  saline  colon  flushings  at  a  temperature 
of  115°  F.  were  ordered  to  stimulate  diuresis.  A  bland  liquid  diet  aided  by  liquids, 
lemonade,  and  cream  of  tartar,  formed  the  main  treatment.  The  child  made  a 
brilliant  recovery,  to  the  credit  of  Dr.  Pechner.  There  were  no  complications  after 
the  disappearance  of  the  nephritis. 

Secondary  Nephritis. 

Secondary  nephritis,  following  the  acute  infectious  diseases,  can  best 
be  studied  by  taking  the  type  most  frequently  met  with,  namely,  post  scar- 
latinal nephritis.  (See  chapter  on  "Scarlet  Fever''  for  a  complete  descrip- 
tion of  this  condition.  Note  also  the  microscopical  appearance  of  the 
urine  in  the  same  chapter,  page  658.) 

Treatment. — Cream  of  tartar  lemonade,  a  teaspoonful  of  cream  of 
tartar,  added  to  a  tumblerful  of  ordinary  lemonade,  and  sweeten.  This 
should  be  given  freely.  Another  drug  that  has  served  me  very  well  is 
diuretin;  this  should  be  administered  in  doses  of  from  3  to  15  grains, 
depending  on  the  age.  This  can  be  repeated  every  three  or  four  hours, 
depending  on  the  severity  of  the  case.  When  diuretin  is  not  well  borne  by 
mouth,  I  give  it  in  the  form  of  suppositories  per  rectum. 

The  following  has  served  me  very  well  as  a  diuretic  in  nephritis  when 
the  urine  was  scanty: — 

IJ  Potass,  citrat 2  */,  drachms 

Ext.  buchu.  fluid  2 '/,  drachms 

Ext.  uva  ursi  fl 1  drachm  1  scruple 

Syr.  limonis 2  ounces 

Aqua q.  s.  ad  4  ounces 

Sig.:     Teaspoonful  every  two  or  three  hours. 

Calomel  or  podophyllin,  in  small  doses,  ^/^o  grain,  repeated  every  two 
or  three  hours,  \&  sometimes  valuable  in  this  condition.    Lithia  water  and 


PERINEPHRITIS.  409 

the  alkaline  waters  are  generally  indicated.  An  infusion  made  by  scalding 
the  ordinary  parsley  root  (rad.  petrosilini),  using  about  one  teaspoonful 
of  the  chopped  root  to  a  teacupful  of  boiling  water,  strain  and  sweeten. 
This  can  be  given  in  large  quantities  whenever  the  child  is  thirsty.  Sweet 
spirits  of  niter  in  doses  of  Vj  teaspoonful,  gradually  increased,  for  a  child 
1  to  5  years  old,  and  repeated  every  three  hours,  is  a  safe  and  efficient 
diuretic. 

Jaborandi  or  its  alkaloid,  pilocarpine,  are  frequently  advised  as  diu- 
retics. I  have  frequently  seen  such  cardiac  depression  follow  their  admin- 
istration that  I  invariably  warn  against  their  use.  In  conclusion,  I  desire 
to  lay  great  stress  on  the  weakness  of  the  heart  frequently  noticed  after 
the  administration  of  the  hot-air  bath.  In  one  instance  where  I  was  called 
in  consultation,  the  child  died  during  the  administration  of  such  a  bath. 

Perinephritis. 

An  acute  inflammation  involving  the  cellular  tissue  which  surrounds 
the  kidney,  as  a  rule  terminating  in  suppuration.  Some  cases  may  resolve 
without  suppuration. 

Etiology. — It  may  be  associated  with,  or  due  to  suppurative  process  in 
the  kidneys.  It  is  also  found  in  tubercular  conditions.  The  most  frequent 
cause  undoubtedly  is  traumatism.  Idiopathic  conditions  are  frequently  a 
distinct  factor. 

Perinephritis  is  not  of  frequent  occurrence.  Townsend  gives  the  fol- 
lowing statistics:  "Nieden,  in  1897,  found  records  of  166  cases.  Twenty- 
three  of  these  were  under  15  years  of  age,  the  youngest  being  five  weeks 
old.  In  1880  Gibney  reported  a  total  of  28  cases;  the  ages  varied  from 
1  V2  to  15  years.  In  16  there  was  suppuration;  in  12,  no  suppuration.  In 
19  cases  no  cause  was  found;  in  8  cases  a  cause  was  given.  Fenwick  re- 
ports 76  cases :  4  children  under  10  years,  and  9  between  10  and  20  years, 
the  youngest  being  fourteen  months  old.  Kustre  makes  a  report  of  230 
cases,  24  under  10  years  of  age,  17  between  10  and  20  years.  Johnson,  in 
an  experience  of  nine  years  in  Roosevelt  Hospital,  saw  but  one  case  in  a 
child,  a  perinephritic  abscess  in  a  boy  of  10  following  a  fall,  not  complicated 
by  a  kidney  lesion,  Israel,  in  a  report  of  43  cases,  speaks  of  one  in  a 
patient  12  years  old." 

Out  of  3689  patients  treated  in  the  outdoor  department  of  the  Chil- 
dren's Hospital  for  the  Eelief  of  the  Ruptured  and  Crippled,  in  New  York, 
during  1894-1903,  only  6  cases  are  reported  by  Townsend. 

Pathology  and  Bacteriology. — As  a  rule  80  per  cent,  of  the  primary 
cases  terminate  in  abscess.  In  secondary  cases  an  abscess  is  always  found. 
The  pathological  condition  is  the  same  as  is  found  in  every  acute  inflam- 
mation. The  pus  contains  either  the  streptococcus,  the  staphylococcus,  or 
colon  bacillus.     In  rare  instances  the  pneumococcus  and  the  typhoid  ba- 


410  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

cillus  are  present.     In  tubercular  manifestations  the  tubercle  bacillus  will 
be  found. 

Symptoms. — A  child  that  has  been  in  good  health  will  suddenly  de- 
velop pain  in  the  region  of  the  kidney  near  the  vertebra.  The  pain  extends 
downward  and  simulates  sciatica.  Moving  the  body  increases  the  pain, 
hence  the  spine  is  generally  rigid.  For  this  reason  alone  many  cases  are 
mistaken  for  Pott's  disease.  There  will  also  be  fever,  the  temperature 
ranging  between  102°  and  104°  F.  If  the  child  is  old  enough  to  complain, 
then  chills  will  be  noted.  In  the  ileo-costal  region  there  is  usually  a  pal- 
pable tumor.  Children  so  afflicted  will  refuse  to  walk  on  the  affected  side, 
and  will  limp.  They  describe  the  pain  as  though  it  were  in  the  groin,  in 
the  hip,  or  sometimes  in  the  knee-joint.  If  pyelitis  complicates,  the  urine 
will  contain  pus.    Owing  to  the  passive  condition  there  is  constipation. 

A.  B.,  9  years  old,  complained  of  pain  in  the  gi-oin  and  also  in  the  back  on  the 
left  side.  He  limped  and  could  not  stand  on  his  left  leg.  He  complained  of  chills 
and  his  temperature  rose  to  103°  F.  He  urinated  very  frequently.  After  a  careful 
examination  the  urine  was  found  to  contain  nothing  abnormal.  The  boy  was  put  to 
bed.  The  bowels  were  flushed.  Owing  to  small  roseolar  spots  which  appeared, 
typhoid  fever  was  suspected.  The  blood  reaction  for  Widal  was  absfent.  The  urine 
gave  no  diazo  reaction.  The  pain  increased,  and  after  ten  days  of  expectant  treat- 
ment a  swelling  was  noted  in  the  loin. 

This  swelling  gradually  increased  in  size  until  it  was  as  large  as  a  hen's  egg. 
A  surgeon  was  called  who  diagnosed  perinephritis.  An  incision  was  made  and  two 
ounces  of  pus  liberated.  The  wound  was  packed  with  sterile  gauze,  and  with  rest, 
iron,  and  strychnine  internally,  the  boy  recovered  in  about  five  weeks. 

Diagnosis. — This  condition  may  be  confounded  with  hip- joint  disease, 
but  hip-joint  disease  develops  very  slowly  and  has  a  tendency  to  become 
chronic.  The  symptoms,  while  very  similar  in  perinephritis,  develop  sud- 
denly from  within  a  few  days  to  a  few  weeks,  and  recovery  may  occur  within 
a  few  weeks  after  the  first  symptoms  are  noted.  In  hip-joint  disease  the 
symptoms  extend  over  months  and  years. 

The  Blood. — An  important  diagnostic  point  is  the  increase  in  the  num- 
ber of  leucocytes,  such  as  we  find  in  purulent  conditions  in  other  parts  of  the 
body.     In  tuberculosis  there  is  no  leucocytosis  unless  sepsis  exists. 

Prognosis  and  Course. — Primary  perinephritis  runs  an  acute  short 
course  of  a  few  weeks  and  usually  terminates  favorably.  Gibney  reports 
28  cases,  all  of  which  recovered. 

Treatment. — Eest  in  bed  and  a  warm  poultice  over  the  affected  area  to 
hasten  suppuration.  The  abscess  should  be  treated  on  strict  surgical  prin- 
ciples. No  time  should  be  lost  when  fluctuation  is  felt,  owing  to  the  danger 
of  pus  burrowing  into  the  peritoneal  cavity. 

Eestorative  treatment,  such  as  diet,  fresh  air,  iron,  and  codliver-oil, 
should  form  the  basis  of  the  building-up  process.  t| 


PYELITIS.  411 

Pyelitis  (  Pyelonephritis  ) . 

This  condition  is  rarely  met  with  in  practice.  Literature  records 
isolated  cases.  Monti,  of  Vienna;  Baginsky,  Steffen,  and  Holt  are  among 
those  who  have  reported  cases  of  this  kind. 

Causes. — Pyelonephritis  occurs  at  all  ages,  but  is  more  common  in 
adult  males  than  in  the  young.  The  exciting  causes  in  adult  males  are 
stricture  of  the  urethra,  renal  calculi,  prostatic  diseases,  and  infection  by 
means  of  dirty  catheters.  That  girls  seem  to  have  been  favored  by  this 
disease  can  be  seen  by  referring  to  the  literature;  thus  Professor  Baginsky 
reports  three  cases,  all  girls,  in  the  Deutsch.  Med.  Wochenschrift,  1897, 
No.  25,  which  he  discussed  at  the  Verein  fiir  Innere  Medicin  in  1897. 
In  these  three  cases  the  author  was  able  to  grow  a  culture  of  the  bac- 
terium coli  from  the  urine.  He  believes  the  bacterium  coli  to  be  the  true 
etiological  factor  in  this  disease.  In  these  three  cases  there  were  marked 
gastroenteric  disturbances,  in  two  cases  membranous  enteritis  and  obstinate 
constipation.  In  my  case  here  reported  there  was  severe  constipation  requir- 
ing constant  treatment. 

Baginsky  further  maintains  that  the  bacterium  coli  can  enter  the 
kidneys  through:  first,  the  circulation  of  the  blood;  second,  the  lymph 
channels;    third,  the  urethra. 

Escherich,^  Finkelstein,-  and  Trumpp^  have  reported  a  series  of  cases 
in  which  cystitis  was  found  associated  with  intestinal  affections.  Baginsky 
reports  two  cases  of  pyelonephritis  which  could  be  attributed  to  the  method 
of  using  gymnastics  during  orthopaedic  treatment  for  the  correction  of  con- 
genital dislocation  of  the  hip  joint.  In  connection  with  the  exercises  a 
direct  invasion  of  the  bacterium  coli  from  the  urethra  to  the  bladder  could 
be  traced.  Other  authors,  as  Posner,  believe  that  external  influences  have 
no  bearing  on  the  etiology,  and  that  the  infection  takes  place  from  within 
the  body.  It  is  a  well-known  fact  that  gonorrhoeal  vulvo-vaginitis,  espe- 
cially when  it  occurs  in  little  girls,  can  cause  either  pyelitis  or  pyelone- 
phritis. This  is  termed  the  ascending  variety.  Chronic  occlusion  of  the 
ureter  may  be  followed  by  a  pure  pyelonephritis,  without  preceding  cystitis, 
when  the  exciting  agents  of  inflammation,  which  are  present  in  the  cir- 
culating blood,  are  eliminated  through  the  kidneys  and  collect  in  the  stag- 
nating urine  in  the  pelvis  of  the  kidneys.  Experimentally  this  disease  can 
be  produced  in  rabbits  by  ligating  the  ureter  and  injecting  either  bacterium 
coli  or  pyogenic  cocci  directly  into  the  pelvis  of  the  kidney  or  into  the 
veins. 


^Mitthoil.  (1.  Voroins  dor  Aorzto  in  Stoionnark.   1804. 
M'^ink(>lst('in,  .liilirl)\ifli   f.    KindcrlicilUuiulc,  Hand  xliii,  pago  148. 
^ 'l'niiiii)|).  //)/'/..  Hand  xliv,  page  249. 


412 


DJSKASKS  Ol'    11  IK    KIDXKV   AM)   JU.AJ)])KR. 


Pathology. — Tncrcascd  ])ix'ssiii'c  in  the  tulmles  ffom  obstruction  to  the 
escape  of  lu'iiu';  I'cHex  irritation  oL'  the  ki(hu'y:  the  })r('seiu"e  ol'  septic 
matter  in  the  pelvis  of  the  ki(hicv  and  ])ossihly  in  the  hnvcv  parts  of  the 
tubules.  Most  l'rt'((uentl_v  these  three  causes  act,  in  sui-eessioii  ami  in  the 
nbove  ortler,  in  the  same  ease.  As  a  rule,  when  acting'  sinLily,  increased  pres- 
sure from  obstruction  will  ])i-oduce  hydronephrosis;  i-etlex  in'itation  'will 
excite  one  of  the  transient  oi'  eoni;esti\('  types  of  ui'inary  I'evei' ;  aiul  septic 
matter  in  the  ])t'l\is  of  the  kidney  will  cause  acute  or  suppurative  ])velone- 
phi-itis.  Increased  urinary  pressui'e  alone  often  pi'oduces  chi'onic  inter- 
stitial nephritis  as  well  as  sacculation  and  dilatation  of  the  kidney;  luit  it 
rarely,   if  I'ver,  causes  acute  or  subacute  interstitial   nephritis.     Dt-compo- 


Fif,'.   121. — Fever  Curve  in   Pyelonephritis.      (Original.) 


sition  of  urine  in  the  bladder  or  pelvis  of  the  kidney  may  produce  suppura- 
tive changes  in  the  kidney's.  If  the  dilatation  of  the  kidney  is  not  compli- 
cated by  suppurative  pyelitis  hydronephrosis  results.  If  it  is  so  compli- 
cated, pyonephrosis  is  produced.  Klebs  and  others  believe  that  bacteria  have 
migrated  to  the  pelvis  and  calices  of  the  kidney,  there  to  produce  their 
destructive  changes,  hence  the  names  of  parasitic  nephritis  and  ]iyelo- 
iK'])hritis  as  propo.sed  by  Klebs. 

Lindsay  Steven  in  a  thesis  on  the  })athology  of  the  suppurative  inflam- 
mations of  the  kidney,  published  in  the  Gla-'^gair  Medical  Juurnal,  Septem- 
ber, 1.SS4,  corroborates  Klebs's  view  and  expresses  a  decided  opinion  that 
micro-organisms  are  at  the  root  of  the  infection,  and  cause  the  formation 
of  multiple  renal  abscesses  consecpient  on  diseases  of  the  lower  urinary 
passages.  He,  however,  considers  that  there  are  two  ways  whereby  the  par- 
ticular virus  gains  access  to  the  kidney  and  sets  up  suppuration  in  many 
different  points,  namely:  first,  by  means  of  the  uriniferous  tubules,  and 
second,  by  means  of  the  lymphatics  of  the  ureter  and  kidney. 


ECTOPIA  VESICAE  CONGENITALIS.  413 

Steven  shows  that  the  lymphatics,  quite  indepeudently  of  any  otlier 
channel,  may  form  the  pathway  of  the  virus  from  the  bladder  to  the  kidney. 
He  admits  that  the  two  ways  mav  be  more  or  less  combined  in  many  cases; 
so  that  multiple  miliary  abscesses  may  originate  in  the  same  kidney,  partly 
])}■  the  invasion  of  micrococci  along  the  ureter  and  uriniferous  tubules,  and 
]iai-tly  l)y  their  inroad  along  the  lym])]iatie  tracts  of  the  kidney. 

Traube  and  others  who  do  not  think  that  the  bacteria  themselves 
excite  the  inflammation,  consider  that  tliese  organisms  cause  the  decom- 
position of  urea  into  carbonate  of  ammonia  and  that  this  in  turn  excites 
the  inflammation  of  the  mucous  membrane  of  the  kidney. 

Prognosis. — The  prognosis  is  grave  and  depends  on  the  toxin  caused 
l)y  the  presence  of  the  pus.  The  outconu^  of  tlie  case  depends  on  the  dis- 
aj)pearance  of  the  pus  in  the  urine,  which  must  l)e  watched  for  at  times. 

Treatment. — A  child  suffering  with  pyelitis  should  be  put  to  Ijed  in 
a  cool  room  having  plenty  of  fresh  air  and  sunlight. 

Dietetic  treatment  such  as  milk  with  some  alkaline  water  is  useful. 
Xo  solid  food  should  be  permitted.  Whey,  soups,  broths,  and  fruit  juices 
may  I)e  given.  Oranges  and  lemons,  owing  to  their  diuretic  effect,  are 
valuable.  "^I'lie  internal  use  of  lionceguo  water  or  Wildungen  water  is  also 
rct-ommended  for  its  diuretic  effect. 

Diuretin,  in  2  to  10-grain  doses  three  times  a  day,  is  sometinu's  useful. 
Urotropin  is  a  very  valuable  drug  and  serves  both  as  a  diuretic  and  as  an 
internal  antiseptic. 

The   Bladder. 

The  bladder  takes  up  almost  all  of  the  lower  portion  of  the  abdomen, 
as  it  is  capable  of  marked  distention  when  filled.  To  make  proper  physical 
e.vamination  the  bladder  should  be  emptied  by  catheter. 

Tioteh  refers  to  a  distinguished  laparotomist  who  did  not  empty  the 
l)ladder  of  a  child  before  operating  for  an  appendicitis;  on  opening  the 
abdominal  cavity  lie  cut  directly  through  the  walls  of  the  bladder.  The 
ui'ine  flowing  out  reminded  him  of  his  failure  to  appreciate  the  fact  that 
ill  eai'lv  life  the  bladder  is  essentiallv  an  abdominal  oriran. 


KtTOIMA     \'kSIC.E     CoKGEXrTAI.IS     ( EXTROVKItSIOX     OF    THE     l)I.ADI)i:i;  : 
EXSTHOI'HY    OF    TIIF     BlADDER). 

This  anatomical  peculiarity  is  due  to  dellcieiit  closure  of  the  iieutrnl 
laminjc  causing  this  hiatus  of  the  abdominal  wall  in  some  cases.  "The 
lower  ])art  of  the  abdominal  wall,  from  the  umbilicus  or  its  neighborhood 
downward,  may  fail  to  close,  and,  coupled  with  this,  there  may  be  deficiency 
of  the  anterior  wall  of  the  bladder."     This  constitutes  extroversion,  some- 


414 


J)1SKASES  OF  TllK   Kll)Xi:V   AM)   I'.LADDER. 


times  called  exstrophy  of  the  bladder.     The  ureters  are  plainly  visible  and 
the  urine  dribbles  continuously.     The  child  is  constantly  wet  and  excoriated 
from  the  moisture  and  its  irritation.     'V]\c  uiine  is  passed  in  distiiicl  jets. 
or  streams,  and  is  es])ecially  noticeal)lc  wlicii  the  child  cries  or  strains. 

The  following  case  was  presented  by  me  to  the  cliildren's  clinic  of  the 
New  York  I'ost-Graduate  ]\Iedical  School  and  Hospital.^ 

A  female  infant.  1  year  old.  was  seen  by  nie.  8]ie  was  breast-fed  and  widl- 
nourished.  Soon  after  birth  the  mother  noticed  a  constant  dribbling  of  luiitc  and 
attention  was  directed  to  a  swelling  situated  in  the  region  of  the  umbilicus.     The 


Fig.    122. — lv\stro])hy   of   the    Bladder,   and    Prolapse    of   Anus.    (Original.) 


diagnosis  of  exstrophy  of  the  bladder  was  made.  .\  bland  ointment  was  prescribed 
to  relieve  the  e.vcoriation  from  the  constant  dribbling  of  urine.  As  this  case 
required  a  plastic  operation  it  was  referred  to  Dr.  Carl  Beck,  at  the  St.  ^larks 
Hospital,  for  surgical  treatment. 


1  This  case  was  also  presented  by  me  at  the  Scientific  Society  of  Oerman   I'liy- 
sicians  lield  at  the  residence  of  Dr.  A.  .Jacobi  about  ten  years  ago. 


PYURIA.  415 

A  child  ill  tliis  condition  should  not  he  operated  upon  until  3  or  4 
years  of  age. 

IXDICANURIA. 

A  trace  of  indicau  is  found  in  the  urine  in  health.  A  very  strong 
indican  reaction  should  always  he  regarded  as  abnormal  and  hence  it  is 
pathological.  As  indican  is  derived  from  indol  it  signifies  a  product  of 
decomposition  and  denotes  putrefaction  of  the  proteids.  It  has  also  been 
found  in  eniiiyeiiia  and  in  extensive  suppurative  processes  where  putrefac- 
tion abounds.  Stagnant  fgeces,  constipation,  chronic  intestinal  indigestion, 
and  some  forms  of  putrefactive  diarrhoea  will  give  a  strong  indican  reaction. 
Herter  has  rei)orted  the  presence  of  indican  in  the  urine  in  cases  of 
epilepsy  at  the  time  of  the  seizures.  In  the  early  stages  of  typhoid  fever, 
when  the  diagnosis  is  doubtful,  the  presence  of  a  Diazo  reaction  and  the 
absence  of  indieanuria  is  a  valuable  aid  in  the  diagnosis. 

Eliminative  treatment  such  as  cleansing  the  gastro-intestinal  tract, 
besides  reducing  the  amount  of  meat  and  eggs,  will  relieve  an  excess  of 
indican  (see  article  on  "Intestinal  Indigestion"). 

ACETOXURIA. — DlACETOXURIA. 

We  are  indebted  to  Baginsky  for  a  careful  study  of  this  condition.  He 
found  that  it  was  present  in  children  during  epileptic  attacks.  It  is  also 
found  dui'ing  the  height  of  fever.  He  does  not  l)elieve  that  acetonuria  bears 
any  relation  to  the  nervous  symptoms  which  accompany  fever. 

Diacetonuria  is  very  common  during  high  fever.  It  is  more  frequently 
])resent  than  acetonuria.  Binet,  (pioted  by  Holt  found  diacetic  acid  in 
sixty-nine  out  of  one  hundred  and  fifty  examinations  in  febrile  diseases, 
chiefly  in  scarlet  fever,  measles,  and  pneumonia. 

Pyuria. 

^\'hen  pus  is  found  in  the  urine,  it  gives  a  reaction  like  albumin,  namely, 
coagulates  on  l)oiling.  I'us  cells,  however,  can  be  seen  only  l)y  placing  a 
drop  under  the  microscope,  using  low  power.  While  pus  usually  indicates 
])yelitis  or  pyelonephritis,  it  may  exude  from  the  ureters,  the  bladder,  the 
urethra  or  the  vagina. 

Tubercular  or  suppurative  conditions  aifectiug  the  spine  associated  with 
caries  of  the  spinal  vertebrcr  may  drain  into  the  urinary  tract.  It  is 
iuiportant,  therefore,  to  locate  the  cause  before  treatnumt  is  commenced. 

Pus  from  the  bladder  is  always  mixed  with  mucus.  It  may  be  acid  or 
alkaline  in  reaction.  Tlie  urine  containing  pus  due  to  pyelitis  has  an  acid 
reacts)!!.     If  the  child  is  old  enough,  a  cystoscopic  examination  should  be 


41(3  DISEASES  OF  Till-:   KIDNKV  AXI)  T.l.ADDER. 

made.     This  will  aid  in  excluding  the  hladdtT  and  the  ureters  as  a  possible 
source  of  the  ])us. 

Treatment. — Demulcent  drinks,  alkaline  waters,  such  as  the  Wildungen 
water,  have  a  mild,  diuretic  effect.  Salol  and  urotropin  are  the  best  drujjs 
in  doses  of  two  to  li\e  grains  three  times  a  day.  3lilk,  cereals,  and  fruits 
should  be  ordered  ;    meat  and  eggs  prohildted. 

DlABKTKS      IXSIPIDUS      (POLYURIA). 

This  is  a  very  rare  eoiidition  in  ehildri'ii.  Its  etiology  is  obscure 
although  males  arr  more  rrc(|iientiy  attacked  than  females.  Little  is  known 
of  its  origin  exce})ting  that  traumatism  involving  the  l)rain  has  been  known 
to  be  followed  by  diabetes  insipidus. 

The  pathology  of  this  disease  is  miknown.  It  is  supposed  to  l)e  a 
neurosis  but  whether  the  lesion  is  near  the  fourth  ventricle,  or  whether  its 
seat  is  in  the  renal  nerves,  has  not  yet  been  determined. 

Symptoms. — Excessive  thirst  and  an  excess  of  urine  constitute  the  main 
symptoms.  From  iive  to  ten  pints  or  even  more  may  be  passed  in  twent\- 
four  hours.  The  urine  looks  like  water  and  has  a  specific  gravity  from 
1001  to  1005.  In  some  cases  mosite  (muscle  sugar)  has  been  found  (Holt). 
Al])umin  and  grape  sugar  are  not  formd.  Urea  is  excreted  in  large  quan- 
tities, wliereas  iiric  acid  is  not.  Restlessness  by  cla}^,  headache,  insomnia, 
and  marked  irritability  are  the  chief  symptoms.  Unilateral  flushes  of  the 
face,  and  one  ear,  and  similar  vasomotor  disturbances  are  present.  There 
IS  an  absence  of  perspiration.  The  skin  is  dry.  Development  is  retarded, 
especially  growth.  The  appetite  renuiins  good.  The  temjierature  may  be 
subnormal. 

Prognosis. — The  disease  has  been  knoAvn  to  last  years.  Some  cases 
recover  spontaneously.  As  a  rule  it  is  Avise  to  give  a  guarded  prognosis. 
Cases  of  diabetes  insipidus  are  very  susceptible  to  other  diseases  and  usually 
die  from  some  comj)lication. 

Treatment. — A  very  nutritious  diet  consisting  of  milk,  meat,  eggs,  and 
fruit  with  some  restriction  as  to  the  (|uaiitity  of  liquid  should  be  made. 
Eestoratives  such  as  Fowlei''s  solution,  iron,  and  cod-liver  oil  will  sometimes 
do  good.  When  marked  nervous  symi)toms  exist,  then  atropine,  Dover's 
powder,  belladonna  and  the  bromides  nuiy  be  tried.  Change  of  air  such  as 
an  ocean  voyage  or  mountain  air  may  be  of  benefit. 

Lordotic  Albuminuria    (Orthostatic  Albuminuria). 

Heubner  has  directed  attention  to  the  presence  of  albumin  in  the 
urine  when  children  are  standing  erect.  The  albumin  disappears  when  tlie 
child  assumes  a  horizontal  position,  hence  albumin  will  be  present  by  da}^, 
and  will  disappear  in  the  urine  voided  at  night. 


HjarATURiA.  417 

Jehle,  of  Vienna,  in  liis  monograph  published  in  1909,  lias  studied  this 
question  more  closely,  and  finds  a  different  cause  for  the  presence  of  the 
albumin  in  the  urine.  He  finds  that  when  lordosis  is  present,  and  in  eon- 
sequence  the  lumbar  vertebrie  offend  the  kidneys  Ijy  displacement  or  pres- 
sure, that  albumin  will  at  once  appear  in  the  urine.  That  this  is  no  theory 
he  shows  by  producing  an  artificial  lordosis.  When  in  the  dorsal  position 
alljumin  will  be  found  in  the  urine  and  disappear  when  such  pressure  is 
removed.  This  presence  of  albumin  is  found  in  nornuil  kidneys  in  which 
no  previous  scarlatinal  or  other  forms  of  nephritis  have  existed.  It  is, 
tlierefore,  a  mechanical  ty])e  of  allnnninuria  which  can  be  made  to  appear 
during  the  lordosis  and  to  disappear  when  the  lordosis  is  corrected. 

H.EMATUKiA   (Bloody  T'rixe). 

Ha?matuiia  is  known  l)y  the  presence  of  red  blood-cells  in  the  urine.  It 
may  be  due  to  local  irritation  or  to  systemic  disease.  It  is  therefore  fre- 
quently met  with  during  the  course  of  a  severe  attack  of  acute  nephritis, 
complicating  scarlet  fever.  A  case  of  this  kind  is  reported  in  the  chapter 
on  "Scarlet  Fever."  I  have  frequently  seen  ha?maturia  during  the  course 
of  the  ha?morrhagic  form  of  diphtheria,  while  on  duty  at  the  Willard 
Parker  Hospital.      1  have  also  seen  luvmaturia  in  scurvy. 

It  is  im])ortant  to  remember  that  irritation  caused  by  a  calculus  in 
the  kidney,  the  ureter,  or  the  bladder  nuiy  give  rise  to  bloody  urine.  Direct 
injury  to  the  kidney  or  Idadder,  or  a  tumor  in  the  bladder,  may  cause 
Ijloody  urine. 

The  general  causes  frequently  met  iriili  are  ha^morrhagic  diseases  of 
the  new-l)orn  ;  the  blood  dyscrasia?,  such  as  scurvy,  pur])ura,  and  ha-ino- 
philia;  and  infectious  diseases,  particularly  malaria,  typhoid,  variola,  scar- 
let fever,  and  influenza.  In  most  of  these  cases  the  amount  of  blood  passed 
is  small.  A\'hen  it  is  large  it  may  appear  in  the  urine  as  clear  blood  or  as 
clots,  or  it  nuiy  im])art  simply  a  reddish  or  smoky  color  to  the  urine.  The 
color,  however,  is  not  a  reliable  guide;  the  best  of  all  is  the  microscopic 
examination.     For  a  simple  chemical  test  guaiacum  may  be  used    (Holt). 

It  is  a  didicult  matter  to  discover  the  source  of  l)lood  in  some  cases, 
although  large  lia'morrhage  is  more  apt  to  result  from  the  kidnevs  than 
IVom  the  bladder.  To  differentiate  we  must  rely  on  the  presence  of  casts 
from  the  renal  tubules;  thus  we  can  satisfy  ourselves  of  the  renal  or'ujin 
of  the  luvmoi'rhage. 

The  prog-nosis  depends  on  the  amount  of  haemorrhage  and  the  general 
condition  of  the  child.  It  should  always  be  regarded  as  a  bad  sym])t()m, 
althouLih  not  ncccssarilv  fatal. 


418  J)ISKASE.S  OF  Tlll>:  KIDNEY  AND  liLADDER. 

Treatment. — The  application  of  an  ice-bag  oi-  dry  cups  over  the  region 
of  the  kidneys,  rest  in  bed,  Squibb's  ergot,  gallic  acid,  3  to  10  grains, 
repeated  every  three  or  four  hours,  or  the  fluid  extract  of  hydrastis  cana- 
densis, in  3  to  10-drop  doses,  for  a  child  2  years  old,  repeated  every  three 
or  four  hours,  will  sometimes  do  good. 

The  food  is  best  given  either  cool  or  very  cold.  If  the  child  is  old 
enough,  small  pieces  of  cracked  ice  or  ice  cream  may  be  given  until  the 
blood  disappears. 

HiEMOGLOBINURIA. 

Instead  of  blood  cells  in  the  urine  this  condition  manifests  itself  by 
the  presence  of  Mood  pigment  in  the  urine.  Sometimes  the  urine  is  I)lackish. 
Alljumin  may  frequently  be  found  associated  with  haemoglobin.  The 
pathology  of  this  condition  is  at  present  unknown.  It  is  very  easy  to 
recognize  the  pigment  under  the  microscope.  It  can  also  be  noted  by 
Heller's  test.     The  most  positive  method  of  diagnosis  is  the  spectroscope. 

Not  infrequently  this  condition  is  met  with  in  the  infectious  diseases, 
which  is  evidently  due  to  the  effect  of  the  toxins  generated  by  the  specific 
micro-organisms  causing  these  diseases.  When  an  irritant  poison,  such  as 
carbolic  acid,  is  swallowed,  this  condition  is  encountered  and  recognized, 
clinically,  by  the  familiar  term  "smoky  urine." 

Paroxysmal  luemoglobinuria  is  occasionally  met  with  in  childhood. 
It  is  usually  associated  with  syphilis.     Other  cases  have  been  reported.^ 

Glycosuria. 

The  appearance  of  sugar  in  the  urine  is  not  necessarily  pathological. 
Grosz  published  a  series  of  investigations  dealing  with  this  condition.  He 
found  that  glycosuria  occurs  in  nursing  infants  who  have  either  functional 
or  inflammatory  disturbances  of  digestion.  He  did  not  see  it  in  perfectly 
healthy  nursing  infants.  The  sugar  found  in  the  urine  reacts  to  Fehling's 
test;  it  does  not  respond  to  the  fermentation  test.  The  polariscope  shows 
that  it  has  the  power  of  dextro-rotation,  so  that  tlie  sugar  present  is  pos- 
sibly milk  sugar  or  one  of  its  derivatives. 

Artificial  glycosuria  can  be  produced  by  administering  a  large  quan- 
tity of  milk  sugar  in  the  food,  hence  it  may  be  presumed  that  t^he  sugar 
excreted  in  the  urine  is  simply  the  excess  of  what  could  not  be  absorbed  in 
the  system. 

Glycosuria  was  frequently  noted  by  me  in  the  urine  of  children  fed 
exclusively  on  Xestle's  food.  When  this  form  of  feeding  was  discontinued, 
the  glycosuria  disappeared.  These  cases  could  therefore  be  classified  under 
the  head  of  dietetic  glycosuria. 


1  Archives  of  rediatrics. 


COLICYSTTTIS.  419 

Diabetes  Mellitus. 

Cases  of  this  nature  are  frequently  met  with  in  cliiklren.  The  pathol- 
ogy  is  as  yet  rather  dark.  Of  the  etiological  factors  heredity  must  cer- 
tainly be  considered.  Parvy  reports  the  case  of  a  child,  2  years  old,  that 
died  of  diabetes,  in  whose  family  the  disease  had  exi&ted  for  several  sren- 
erations. 

Symptoms. — Sugar  in  the  urine,  excessive  thirst,  emaciation,  aeetonuria, 
and  polyuria  are  the  most  important  symptoms. 

A  case  of  this  kind  was  seen  I)v  me  in  consultation  with  Dr.  B.  Brodski  of  Xew 
York  City.  A  girl,  about  10  years  old.  sufl'ered  with  excessive  thirst.  She  could  drink 
several  pints  of  water  in  succession,  and  still  complain  of  thirst.  In  the  same 
manner  she  passed  many  times  more  pints  of  urine  than  would  be  normal.  Thft 
appetite  was  poor.  The  child  complained  of  extreme  weakness  and  showed  signs  of 
emaciation.  Sugar  and  acetone  were  found  in  the  urine.  In  spite  of  restorative 
treatment  the  ease  ended  fatally. 

Equally  instructive  were  two  cases  seen  by  me  at  the  children's  service 
of  the  German  Poliklinik.  They  occurred  in  the  practice  of  Dr.  L.  F.  W. 
Haas.  They  were  reported  in  extenso  to  the  Section  on  Diseases  of  Children 
at  the  meeting  held  at  Atlantic  City  in  June,  1900. 

Prognosis. — The  prognosis  is  always  grave.  When  the  urine  contains 
diacetic  and  oxybutyric  acids  the  condition  is  more  serious  than  when  the 
urine  contains  sugar  alone. 

Eoughly  stated,  the  duration  of  the  disease  may  be  about  six  months, 
although  some  children  linger  for  years. 

Treatment. — In  the  diet  milk  and  cereals  are  most  important.  Cod- 
liver-oil,  iodide  of  sodium,  and  Fowler's  solution  are  beneficial.  General 
hygienic  measures,  such  as  sending  the  child  from  the  city  to  the  country  or 
to  the  seashore,  may  be  of  benefit. 

COLICYSTITIS. 

We  are  chiefly  indebted  to  Escherich  for  calling  our  attention  to  this 
condition. 

Bacteriology  and  Pathology. — The  bacterium  coli  commune  gives  rise 
to  this  condition.  The  bacteria  can  migrate  through  the  female  urethra 
and  set  up  a  cystitis.  When  the  intestinal  mucous  membrane  is  not  intact, 
as,  for  example,  in  catarrhal  enteritis,  these  bacteria  can  enter  the  bladder 
by  migrating  through  the  intestinal  mucous  membrane. 

Symptoms. — There  is  fever  and  irritability  of  the  bladder  shown  by 
tenesmus.  The  urine  contains  pus,  sometimes  traces  of  albumin,  and  has  a 
very  foul  odor.  As  a  rule  the  urine  is  milky  or  cloudy,  or  it  may  be  dark 
in  color.  In  some  cases  there  may  be  vomiting  and  headache  associated  with 
pains  in  the  bladder  and  in  the  back. 


420  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

Prognosis. — The  prognosis  is  good. 

Treatment. — Internally,  3  to  5  grains  of  urotropine,  several  times  a 
day,  or  oleum  gaultheria,  1  to  3  drops,  three  times  a  day,  or  salol,  3  to 
5-grain  doses,  three  times  a  day,  may  be  given. 

Locally. — The  bladder  should  be  washed  with  a  double  current  catheter. 
A  weak  permanganate  of  potash  solution  should  be  used,  3  or  4  ounces 
being  injected  at  one  time;  this  should  be  continued  until  several  pints 
have  been  used.  In  some  cases  irrigations  of  a  bichloride  of  mercury  solu- 
tion, 1  to  4000,  repeated  several  times  a  day,  may  be  useful. 

Uretiihal  Calculi  (Vesical  Calculi:    Stone  in  the  Bladder). 

This  condition  is  extremely  rare  in  infancy.  It  is  not  so  rare  in  chil- 
dren after  the  third  year  owing  to  their  solid  diet.  Stone  in  the  bladder 
is  usually  composed  of  uric  acid,  and  is  often  the  result  of  uric  acid  in- 
farction in  the  kidney.  In  this  condition  calculi  pass  from  the  pelvis  of  the 
kidney  through  the  ureters  and  lodge  in  the  bladder. 

Symptoms. — While  urinating  there  will  be  a  sudden  cessation  of  the 
floAV  of  urine.  Pain  either  in  the  penis  or  in  the  perineum  is  sometimes 
described.  As  has  been  described  (in  the  chapter  on  "Cystitis")  whenever 
severe  tenesmus  exists  causing  prolapse  of  the  rectum  without  definite  in- 
testinal trouble,  we  should  suspect  trouble  in  the  bladder.  Incontinence  of 
urine  is  sometimes  present. 

Diagnosis. — If  the  child  is  old  enough  a  diagnosis  can  sometimes  be 
made  by  inserting  one  finger  into  the  rectum  and  pressing  over  the  bladder 
in  the  abdomen  (bimanual  examination).  Although  this  method  of  bi- 
manual palpation  is  frequently  valuable,  it  sometimes  gives  negative  re- 
sults. The  surest  method  is  to  explore  the  bladder  with  a  sound.  In  very 
sensitive  children  cocaine  may  be  injected  into  the  urethra  before  the  sound 
is  passed.  In  exceptional  cases,  only  with  the  aid  of  an  anaesthetic,  can 
a  positive  diagnosis  be  made. 

Treatment. — Such  cases  should  be  treated  by  the  surgeon,  although  an 
attempt  at  crushing  the  stone  might  be  made.  The  radical  operation  of 
supra-pubic  lithotomy  may  be  necessary. 

Very  large  calculi  have  been  seen  by  me  in  the  Stephanie  Children's 
Hospital,  in  Buda-Pest,  through  the  kindness  of  Prof.  Johann  von  Bokai. 
Professor  Bokai  told  me  that  from  certain  districts  in  Hungary  they 
receive  many  cases  of  large  vesicle  and  urethral  calculi.  It  is  therefore 
quite  evident  that  the  calculi  are  intimately  associated  with  the  geographical 
conditions  favoring  the  same. 

Acute  Cystitis. 
This  condition  is  seldom  seen  in  children. 


CHRONIC  CYSTITIS.  421 

Etiologfy. — It  is  most  usually  due  to  the  invasion  of  pathogenic  bac- 
teria, such  as  the  bacterium  coli  and  the  gonococcus. 

It  is  most  frequently  the  result  of  an  extension  of  an  infection  from 
the  external  genitals  through  the  urethra  into  the  bladder,  so  that  blenor- 
rhoea  in  children  may  be  an  exciting  cause  of  acute  cystitis.  It  has  also 
been  known  to  arise  from  typhoid  bacilli  eliminated  through  the  kidneys 
by  the  urine. 

Stone  in  the  bladder  and  intestinal  irritants,  ?uch  as  turpentine  or 
copaiba,  have  been  known  to  cause  cystitis. 

Females  are  more  prone  to  this  affection  than  males. 

Symptoms. — Very  frequent  desire  to  urinate,  accompanied  by  pain  on 
urination,  is  the  principal  symptom.  The  urine  has  a  reddish  color,  but 
later  in  the  disease  has  a  light  color.  Its  specific  gravity  is  high.  The 
reaction  of  the  urine  is  alkaline.  On  standing  there  is  a  thick  sediment 
consisting  of  mucus,  pus,  and  blood.  Microscopically,  there  are  pus  cor- 
puscles, squamous  epithelium,  and  blood-corpuscles.  In  females  it  is  neces- 
sary to  use  a  catheter  in  drawing  off  the  urine  to  obtain  a  specimen  for 
examination,  as  the  epithelium  of  the  bladder  and  the  vagina  are  strikingly 
similar. 

Prognosis. — This  is  invariably  good. 

Treatment. — Bladder  washing  with  mild  antiseptic  solutions,  such  as 
a  1  per  cent,  boric  acid  or  bichloride,  1  to  5000,  or  a  weak  permanganate 
of  potash  solution,  is  useful  in  some  cases.  Alkaline  waters,  such  as  the 
White  Rock,  Lithia,  or  Appollinaris  in  large  quantities  should  be  given. 

Internally  the  diet  should  be  regulated  so  that  the  child  receives  milk 
and  Seltzer,  thin  soups  and  broths,  fruit  and  fruit  juices.  Meat  and  all 
spices  must  be  avoided.     Only  bland  articles  may  be  permitted. 

Drug  Treatment. — Urotropin,  in  doses  of  5  to  10  grains,  several  times 
a  day,  is  very  beneficial,  or  Dover's  powder,  1  or  2  grains,  several  times  a 
day,  will  do  good.  In  very  high  fever  an  ice-bag  can  be  applied  over  the 
bladder. 

Chronic  Cystitis. 

This  condition  is  usually  associated  with  a  malignant  growth  in  the 
bladder,  such  as  a  tumor,  or  frequently  by  stone  in  the  bladder.  It  may 
also  be  due  to  a  general  tuberculosis  with  special  local  manifestations  in 
the  bladder.  The  composition  of  calculus  is  mainly  uric  acid,  with  large 
quantities  of  phosphates  from  the  alkaline  urine. 

Symptoms. — From  the  constant  dribbling  of  urine  the  child  will  have 
an  offensive  urine  smell  resembling  ammonia  about  him. 

There  is  an  irritation  around  the  external  genitals,  due  to  excoriation 
from  the  moisture.  If  stone  is  the  cause  of  this  condition  the  urine  will 
be  interrupted  while  passing  and  the  child  will  complain  of  pain.     The 


422  DISEASES   OF  THE  KIDNEY  AND  BLADDER, 

pain  is  difficult  to  localize,  although  it  is  described  as  being  at  the  end  of 
the  penis.  Girls  will  localize  the  pain  at  the  meatus.  From  severe  tenesmus 
there  may  be  prolapse  of  the  rectum. 

The  urine  resembles  the  urine  of  an  acute  cystitis.  Tubercle  bacilli  are 
found  in  bladder  tuberculosis. 

Prognosis. — This  depends  upon  the  condition  of  the  child  and  on  the 
cause  of  this  affection.  A  cautious  prognosis  is  necessary  in  tuberculous 
affection,  or  if  a  tumor  exists. 

Treatment. — If  a  stone  is  present  the  treatment  is  surgical.  Uro- 
tropin  and  salol  are  very  valuable,  and  I  have  seen  permanent  benefit  from 
their  use. 

IJ  Sodium    sulpho-carbolate 25  grains 

Sig.:  Divide  into  5  powders.  One  powder  every  three  hours  in  an  alkaline 
water,  is  also  beneficial  in  some  cases. 

Bladder  washing  and  the  diet  as  described  in  the  article  on  "Acute 
Cystitis"  should  be  employed  in  chronic  cases. 

When  there  is  a  general  atony  of  the  body  then  this  condition  will  fre- 
quently result  in  the  weakening  of  the  sphincter  vesicas  muscle  or  in  the 
spasm  of  the  detrusor  urinaB  muscle.  Other  conditions  causing  enuresis 
are  lithiasis  vesicalis,  and  where  stones  are  suspected  the  bladder  must  be 
very  cautiously  inspected. 

Children  that  convalesce  from  a  severe  form  of  disease,  such  as  typhoid 
fever  or  any  long  existing  febrile  disorders,  will  usually  have  enuresis  as  a 
result  of  a  general  breaking  down  of  the  body  wherein  the  muscles  lose 
their  tone. 

Other  conditions  causing  irritation  may  be  enumerated  as  congenital 
phimosis  or  adhesions  of  the  prepuce,  strictures  of  the  urethra,  also  irrita- 
tions from  worms,  such  as  ascarides,  commonly  known  as  pin-worms;  fis- 
sures of  the  anus;  frequently  also  in  older  children,  masturbation  and 
vulvitis  may  be  considered  as  possible  causes  of  this  condition.  (Read 
chapter  on  "Lithuria.") 

Calcareous  deposits  in  the  kidneys  or  stone  in  the  bladder,  the  over- 
loading of  the  urine  with  lithates  or  phosphates,  have  frequently  caused 
abnormal  irritations  resulting  in  enuresis. 

Enuresis. 

An  involuntary  emptying  of  the  bladder  during  the  day  is  known  as 
enuresis  diurna.  When  this  condition  exists  at  night  it  is  known  as  enu- 
resis nocturna. 

Causes. — (a)  Organic;    (li)  functional. 

Organic  Causes. — Any  inflammatory  condition  involving  the  urethra 
or  bladder,  or  diseases  of  the  brain  or  spinal  cord,  frequently  cause  this 
condition. 


I 


ENURESIS.  423 

Thiemich*  considers  this  condition,  when  occurring  in  a  child  who 
has  been  clean  for  months  or  years,  and  who  shows  no  sign  of  organic  dis- 
ease of  the  urogenital  or  nervous  system,  as  a  sign  of  that  general  neurosis, 
hysteria.  In  children  hysteria  usually  occurs  in  a  monosymptomatic  form. 
The  children  who  suffer  from  enuresis  at  some  period  usually  come  of  a 
neuropathic  family,  and  later  show  some  other  symptoms  of  hysteria. 

Functional  Causes:  Adenoids. — It  is  not  infrequent  to  find  that  ob- 
structions of  the  nose  and  in  the  naso-pharyngeal  spaces  can  cause  enuresis. 
One  of  the  most  frequent  causes  met  with  is  adenoids.  It  is  a  safe  rule  to 
examine  the  pharyngeal  vault  when  enuresis  exists.  My  experience  has 
been  that  over  50  per  cent,  of  the  cases  of  enuresis  seen  in  my  clinic  have 
adenoid  vegetations. 

Tight  Prepuce. — If  other  irritations,  such  as  a  tight  prepuce  exist, 
then  circumcision  must  be  insisted  upon.  If  irritation  exists  in  the  urine 
on  account  of  an  excess  of  lithates  or  phosphates,  then  internal  treatment 
must  be  directed  toward  relieving  this  condition.  (Eead  article  on  "Lith- 
asmia.'^) 

Prognosis. — The  prognosis  of  this  condition  is  usually  good.  In  ob- 
stinate cases  it  may  be  valuable  to  insist  on  a  change  of  air ;  thus,  removing 
the  patient  from  the  city  to  the  country  or  to  the  seashore  is  of  value  in 
some  severe  cases. 

Treatment. — A  very  bland,  non-irritating  diet,  consisting  of  cereals 
and  milk,  will  be  indicated.  All  spices,  alcoholics,  coffee,  and  tea  must  be 
prohibited.  Do  not  permit  liquids  to  be  taken  before  retiring.  It  is  also 
important  to  have  the  bladder  emptied  immediately  before  retiring. 

Drug  Treatment. — One  of  the  best  drugs  is  strychnine  in  doses  of 
*/ioo  grain,  three  times  a  day,  gradually  increased.  In  addition  thereto 
small  doses,  Vio  grain,  gradually  increased,  of  the  extract  of  belladonna. 
When  a  general  atony  exists  then  nothing  will  be  better  than  iron  given  in 
the  form  of  elixir  of  quinine,  iron,  and  strychnine.  Massage  and  gentle 
friction  of  the  whole  body,  cold  sponging,  especially  of  the  spine,  are  valu- 
able adjuvants  to  the  treatment  of  this  condition.  A  cold  douche  directed 
to  the  spine,  especially  to  the  lumbar  region,  will  be  found  of  great  assist- 
ance. 

Fowler's  solution  and  iron  are  very  valuable  in  weak  children. 

For  incontinence  of  urine,  internally  may  be  given: — 

Ijs  Ext.  rhu3.  aromaticjE,  fl 10  minims 

Syrup  aromalici 20  minims 

Aq.  destillatoe,  ad 1  drachm 

Sig. :     This  amount  to  be  given  three  times  a  day. 

Or:— 


'Berl.  Klin.  Woch.,  vol.  xxxviii.  No.  31. 


424  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

IJ  Liq.  atropine  sulphatis 1  Vi  drachms 

Liq.  strychninae  hydrochloratis 45  minims 

Syr.  aurant ad     1  ounce 

Sig.:  For  a  child  14  years  old,  5  drops  at  night;  increase  gradually.  Younger 
children  in  proportion. 

Tlie  Use  of  Electricity. — Faradic  electricity  applied  over  the  bladder, 
and  also  over  the  lumbar  region  of  the  spine  for  several  minutes  every  day, 
and  gradually  decreased  to  every  two  or  three  days,  is  of  value  in  some 
cases. 

According  to  Thiemich,  excellent  results  are  obtained  by  means  of  pain- 
ful faradization,  not  necessarily  of  the  sphincter  vesicae,  but  of  the  arms, 
back,  or  thighs.  Care  should  be  taken  to  prevent  the  impression  that  the 
treatment  is  a  punishment,  but  instead  it  should  be  explained  that  the 
measure  is  certain  of  success,  even  though  painful.  More  than  one  appli- 
cation is  rarely  required  if  care  and  tact  be  exercised.  As  in  all  forms  of 
hysteria,  isolation  and  removal  from  home  are  the  most  potent  of  all 
remedies. 

Mechanical  Treatment. — The  passage  of  cold  sounds  and  dilatation  of 
the  urethra  by  this  means  is  sometimes  very  effectual.  Elevating  the  foot 
of  the  bed  is  of  value  in  some  cases.  The  child  should  not  be  allowed  to 
sleep  on  its  back.  To  prevent  this  position  it  is  advisable  to  tie  a  towel 
around  the  child's  body  so  that  the  knot  is  in  the  center  of  the  back.  This 
will  awaken  the  child  if  it  turns  on  its  back  and  will  compel  it  to  sleep  on 
the  side. 


PART  VI. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


CHAPTEE  I. 
DISEASES  OF  THE  NOSE  AND  THROAT. 

Acute  Nasal  Catarrh  (Ehinitis,  Coryza). 

Infants  sneeze  normally  during  the  first  few  days  of  life,  the  me- 
chanical irritation  of  dust  in  the  air  being  the  cause  of  the  same.  The 
great  difference  between  the  intrauterine  temperature  and  the  temperature 
of  the  air  renders  the  new-born  baby  sensitive  and  invites  respiratory 
catarrh. 

Etiology. — Pyogenic  bacteria  are  certainly  the  cause  of  the  disease. 
They  will  be  found  in  the  nasal  discharge. 

Eachitic  infants  are  more  prone  to  nasal  catarrh  than  others.  It  is 
most  likely  contagious.  Several  children  in  the  same  family  will  have  the 
disease  at  the  same  time.  The  handkerchief  can  no  doubt  carry  the  con- 
tagium  from  one  to  the  other. 

Children  in  maoy  families  have  a  predisposition  to  catarrh.  There 
are  two  great  extremes: — 

1.  Children  that  are  kept  indoors  and  muffled  up  so  that  their  bodies 
are  overheated,  are  very  sensitive  to  exposure,  and  will  have  nasal  catarrh 
if  exposed  to  a  draught. 

2.  Those  children  who,  in  order  to  be  'Tiardened,"  are  over-exposed 
when  their  skin  is  still  sensitive. 

Symptoms. — There  is  a  hyperaemia  in  the  nasal  passages  causing  ob- 
struction. This  will  compel  the  infant  to  breathe  through  the  mouth. 
Where  nasal  catarrh  exists  there  is  always  an  interference  with  the  feeding. 
The  nose  being  stuffed,  the  infant  must  breathe  through  the  mouth.  There 
is  usually  a  slight  elevation  of  temperature.  The  secretion  which  at  first 
is  thin  and  mucous,  later  on  assumes  a  muco-purulent  character.  This 
latter  discharge  is  thick  and  sticky,  and  while  drying  obstructs  the  nostrils. 

Persistent  catarrh  calls  for  an  exploration  of  the  vault  of  the  pliarynx 
and  suggests  adenoids.  If  present,  no  other  treatment  but  their  removal  will 
remedy  the  catarrh. 

Dia^osis. — Acute  nasal  catarrh  must  not  be  confounded  witli  syph- 
ilitic rhinitis.     The  history  should  be  carefully  noted.     Ehinitis  is  one  of 

(425) 


426 


DISEASES  OF  TIIK  NOSE  AND  THROAT. 


the  earliest  symptoms  of  meas'.e.^,  hence  the  buccal  mucous  membrane  should 
always  be  examined  for  the  presence  of  an  enanthem. 

If  the  temperature  is  high — 102°  to  103°  F. — and  there  is  an  eruption, 
then  the  possibility  of  measles  should  not  be  overlooked.  In  all  cases  of 
measles  the  pharynx  and  tonsils  should  be  carefully  examined.  Diphtheria 
of  the  pharynx  frequently  has  an  acute  rhinitis  associated  with  it.  Per- 
tussis is  very  often  preceded  by  rhinitis.  Inflammation  of  the  lachrymal 
duct  is  at  times  associated,  causing  acute  conjunctivitis.  Sometimes  the 
inflammation  will  extend  through  the  Eustachian  tube  and  cause  otitis. 
In  older  children  deafness  is  frequently  caused  by  closure  of  the  Eu- 
stachian tubes. 

Treatment. — Hygienic  Treatment:  Put  the  child  to  bed  if  there  is 
fever,  but  if  the  temperature  is  normal  then  keep  the  child  indoors  in  a 


Fiff.  123. — Atomizer. 


room  with  a  temperature  of  ?0°  F.  The  body  sliould  l)e  warmly  clad  after 
having  been  given  a  good  tub  bath,  followed  by  friction  with  a  coarse 
Turkish  toweh 

lihinitis  tal)lc'ts,  containing  the  following  ingredients,  for  the  prophy- 
lactic and  general  treatment  of  catarrh  of  the  nose  and  throat,  have  been 
used  by  me : — ■ 

IJ  Soda  salicylate   1  grain 

Tinct.    aconite 1  minim 

Tinot.  belladonna Vio  minim 

Tlie  above  quantity  is  for  one  tablet. 

One  tablet  can  be  given  with  water  every  three  or  four  hours  to  a  child  2 
years  old;    smaller  children  in  proportion. 

Medicinal  Treatment. — The  gastro-intestinal  tract  requires  cleansing. 
A  drachm  of  castor-oil  at  the  commencement  of  treatment  is  beneficial. 
The  best  drugs  are  quinine  and  belladonna  given  internally.  The  quinine 
chocolates,  1  grain  of  quinine,  can  be  given  to  a  child  1  year  old;    to  an 


ACUTE  NASAL  CATARRH.  427 

infant  six  montlis  old  one-lialf  the  dose.  Fluid  extract  of  belladona,  Y^g 
to  V2  minim,  three  times  a  day.  Salol  tablets,  containing  1  grain  of  salol, 
can  be  given  with  benefit  every  three  or  four  hours. 

Local  Treatment. — A  solution  of  adrenalin  chloride,  1  to  10,000^  may 
be  used  to  cleanse  the  nostrils  in  very  young  infants.  In  older  children  a 
solution  of  1  to  4000  may  be  used  for  the  same  purpose. 

The  discharge  can  also  be  removed  by  irrigating  with  a  1  per  cent, 
boracic  acid  or  borax  solution  or  a  1  per  cent,  table  salt  solution,  contain- 
ing some  glycerine,  with  an  atomizer  (see  Fig.  133)  or  with  Lefferts'  poste- 


Fig.  124. — Lefferts'  Posterior  and  Anterior  Nasal   Syringe. 

rior  and  anterior  nasal  syringe,  followed  by  an  alboline  spray.     The  fol- 
lowing prescription  is  useful  for  the  nasal  toilet : — 

IJ  Listerine    V2  ounce 

Table  salt   1   drachm 

Borax   1  drachm 

Water    8  ounces 

Listerine  is  a  comlunation  containing  the  essential  oils  of  thyme, 
eucalyptus,  baptisia,  gaultheria,  and  mentha  arvensis. 

Other  valua])le  preparations  for  cleansing  the  naso-pharyngeal  si)aces 
are  Dol)ell's  solution,  l)orolyptol,  aiul  Seller's  solution. 

Dobell's  Solution. 

^,   Sodium  biborate 1  drachm 

Sodium  bicarb 1  drachm 

Glyc.  of  carb.  acid 2  drachms 

Water   to  make Va  pi»t 

Borolyptol  contains  5  per  cent,  aceto-l^oro  glyceride;  0.2  per  cent,  for- 
maldehyde, in  combination  with  the  active  antiseptic  constituents  of  pinus 
jnimilio,  eucalyptus,  myrrh,  storax,  and  Ijcnzoin. 

This  is  a  very  bland,  mildly  astringent  solution  ada])ted  for  the  naso- 
pharynx. I  frequently  use  this  solution  as  a  menstruum  for  carbolic  acid 
or  bichloride.  All  solutions  used  in  the  nose  should  be  non-irritant,  hence 
caustics  should  be  avoided. 


428 


DISEASES  OF  THE  NOSE  AND  THROAT. 


Seiler's  Solution. 

B  Sod.  bicarb 1  ounce 

Sod.    biborate 1  ounce 

Sod.   benjzoat 20  giaina 

Sol.    salicylate 20  grains 

Eucalyptol   10  grains 

Thymol   10  grains 

Menthol    5  grains 

Oil  of  gaultheria. 6  drops 

Glycerine    8  V»  ounces 

Alcohol    2  ounces 

Water    to  make  16  ounces 


Tablets  sold  in  shops  under  the  name  of  Seiler's  tablets  can  be  dis- 
solved in  4  ounces  of  water.  They  are  of  the  same  strength  as  the  solution 
here  mentioned. 

Cocaine  and  eucaine,  which  are  so  valuable  in  adults,  should  not  be 
used  in  children.  In  older  children  the  inhalation  of  equal  parts  of  tincture 
of  iodine  and  aqua  ammonia  every  half-hour  will  frequently  abort  the 
disease. 

Dietetic  Treatment. — The  nursing  infant  should  be  fed  at  regular 
intervals.     If  bottle-fed  the  same  regularity 

should  be  observed.     No  stimulants  should  /[iH^lr^       /^' 

be  given.  It  is  unwise  to  give  codliver-oil 
or  other  restoratives  when  radical  treatment 
is  called  for. 


rig.   125.^ — Lenox  Nasal  Douche. 


Fig.  126.— Graduated  Douche  Suit- 
able for  Older  Children. 


Naso-piiaryngeal    Catarrh — Frequently    Causes    Gastric    Catarrii. 

The  association  of  naso-pharyngeal  catarrh  with  catarrh  of  the  stomach 
may  at  first  seem  peculiar.  When,  however,  the  anatomical  relationship 
of  the  mucous  membnuie  of  the  naso-pharynx  with  the  oesophagus  and 
stomach  are  considered,  an  extension  of  the  disease  can  easily  be  understood. 
There  are  certain  points  which  have  a  decided  bearing  on  the  etiology  of 
gastric  catarrh  when  caused  by  naso-pharyngeal  disease.     Such  are; — 


FOREIGX  BODIES  IX  THE  NOSE.  429 

1.  The  fact  tliat  children  rarely,  infants  never,  expectorate.  When 
they  have  post-nasal  catarrh  and  there  is  an  irritation  from  mucous  or  muco- 
purulent secretion  infants  invariably  swallow  the  same.  It  is  for  this 
reason  that  the  old-fashioned  dose  of  ipecac  or  castor-oil  was  given,  not  to 
relieve  the  cough  nor  to  hasten  the  expectoration,  but  rather  to  cleanse  the 
stomach  from  non-expectorated  secretion. 

2.  Loss  of  Appetite. — The  loss  of  appetite,  usually  associated  with  se- 
vere naso-pharvngeal  catarrh  in  which  the  stomach  has  been  normal  up  to 
tlie  beginning  of  the  attack,  is  usually  due  to  the  swallowing  of  large  quan- 
tities of  this  infectious  secretion. 

The  benefit  derived  from  curing  a  cold  with  a  dose  of  castor-oil  simply 
means  removing  some  of  the  swallowed  muco-purulent  secretion  from  the 
stomach  which  should  have  been  expectorated. 

When  catarrhal  disease  affecting  the  naso-pharyngeal  space  is  muco- 
purulent and  continues  for  a  long  time  in  very  young  infants,  we  can  easily 
see  why  the  loss  of  appetite  may  be  the  means  of  causing  deficient  nutri- 
tion. Such  cases  may  end  fatally.  The  importance  of  attending  to  diseases 
in  the  naso-pharynx  can  be  seen  when  it  is  considered  that  diphtheria  can' 
spread  from  the  pharynx  to  the  oesophagus,  and  also  to  the  stomach. 

AVhile  it  is  true  that  diphtheritic  gastritis  is  reported  very  rarely,  it  is 
well  to  bear  such  cases  in  mind,  for  they  show  the  great  danger  to  the 
stomach  from  an  infectious  catarrh  located  at  the  food  entrance.  There 
is  usually  a  deficiency  of  hydrochloric  acid  secretion  in  all  severe  catarrhal 
diseases.  This  is  most  apparent  in  those  febrile  conditions  which  accom- 
])any  diphtheria.  It  is  for  this  reason  that  it  is  not  very  difficult  for  the 
stomach  to  be  the  seat  of  an  infection  if  diphtheritic  membrane  is  swal- 
lowed. 

It  is  of  the  greatest  importance  to  have  every  child's  throat  in  a  nor- 
mal condition.  Adenoid  vegetations  and  diseased  tonsils  favor  the  devel- 
opment of  malignant  disease.  The  vast  majority  of  patients  who  are 
infected  with  diphtheria,  owe  tbis  infection  to  the  diseased  state  of  their 
tliroat,  which  favors  the  development  of  pathogenic  bacteria.  This  can 
as  easily  be  verified  in  children  as  in  adults.  It  is  rare  to  find  a  case  of  diph- 
llieria  in  which  a  previous  normal  throat  existed.  Hence  it  would  seem 
jilavsihle  to  eradicate  all  trifling  as  iretl  a.9  serious  nose  and  throat  disea.'ie, 
and  aim  to  secure  a  healthy  state  if  ire  are  to  irard  off  iiifeciions. 

Foreign  Bodies  tx  the  Xose. 

Children  frequently  while  playing  witli  beans,  beads,  shot,  etc.,  stick 
Ihem  in  the  nose.  Tf  allowed  to  remain  they  fi'e(|uently  become  encrusted 
with  caii)onatc  and  phosphate  of  lime.  Then  it  is  kno\\ni  as  a  rhinolith. 
An  angulai-  foi'ceps  or  a  jDolypus  forceps  has  frequently   dislodged   these 


4;^0  D18KASE.S  OF  THE  NOSE  AND  TIIRUAT. 

foreign  bodies.      A  nasal  irrigation  into  the  ini obstructed  nostril  will  some- 
times assist  in  removing  the  foreign  body. 

Tonsillitis  (Angina  Catarrhalis)  . 

This  is  an  acute  inflammatory  lesion,  undoubtedly  due  to  the  infection 
of  the  structures  of  the  tonsil  by  micro-organisms  which  enter  the  lacunar 
or  lymph  channels. 

Bacteriology  and  Pathology. — The  tonsils^  are  lymphoid  structures 
closely  reseml>ling  Peyer's  patches  of  the  small  intestine.  Various  species 
of  cocci  and  bacilli  are  to  be  found  within  the  lacunas,  within  the  closed 
follicles,  and  even  within  the  epithelial  cells  of  tonsils  removed  during  the 
acute  stage. 

Leucocytes  in  large  numl)ers  are  found  associated  with  the  microbes. 

During  the  presence  of  inflammatory  conditions,  such  as  the  presence 
of  the  contagium  of  diphtheria,  desquamation  of  the  ejjithelial  covering 
takes  place.  This  proliferation  of  the  cells  seen  in  diphtheria  may  entirely 
denude  the  tonsils  of  its  epithelial  covering  in  places.  This  will  then  per- 
mit any  specific  virus  to  be  brought  into  contact  with  the  lymphatics  and 
then  be  carried  into  the  general  circulation.  We  see  an  acute  inflammation 
of  the  tonsils  in  scarlet  fever,  in  measles,  and  in  diphtheria.  It  may  also 
be  seen  in  other  infectious  diseases,  so  also  in  acute  inflammatory  mani- 
festations. 

Symptoms. — One  of  the  most  frequent  diseases  of  infancy  and  child- 
hood is  tonsillitis.  When  we  are  told  that  an  infant  has  had  a  slight  fever 
that  passed  off  very  quickly  and  has  been  attributed  to  "teething,"  tonsil- 
litis among  other  diseases  should  be  suspected. 

The  onset  is  sudden.  Fever  is  high.  The  temperature  reaches  102° 
and  may  rise  to  105°  F.  Vomiting  frequently  occurs.  On  the  tonsils  we 
find  intense  redness,  and  the  lacuna  are  covered  with  whitish  or  yellowish- 
white  s])ots,  which  rarely  coalesce  but  appear  as  yellowish  dots. 

Treatment. — Immediate  relief  to  an  inflamed  tonsil  can  be  given  by  a 
spray  of  1  to  10,000  adrenalin  chloride.  Externally  a  hot,  flaxseed  poultice, 
or  in  some  cases  with  fever,  an  ice  collar,  will  render  ffood  service. 

Internally  1-drop  doses  of  tincture  of  aconite,  repeated  every  hour  for 
five  or  six  doses,  will  reduce  fever,  promote  diaphoresis,  and  frequently  abort 
the  condition.  A  dose  of  calomel,  y,  grain,  repeated  every  two  or  three 
hours  until  liquid  stools  are  produced,  is  valuable.  A  steam  atomizer  con- 
taining a  spray  of  l)eechwood  creosote  or  pine  needle  oil,  to  be  used  every 
two  or  three  hours,  loosens  viscid  secretions. 

Food. — As  there  usually  is  pain  on  swallowing  solid  food,  it  is  better 
to  give  small  quantities  of  liquid  food.     Ice  cold  chicken  or  calfsfoot  jelly. 


^Hodenpyl  in  the  Amorioan  Journal  of  Medical  Science,  March  1,  1891. 


THE  SIGNIFICANCE  OF  TONSILLITIS  IN  CHILDREN.  431 

ice  cream,  raw  scraped  pulp  of  meat,  the  yolk  of  raw  eggs  well  beaten  with 
sugar,  buttermilk  or  zoolak,  is  nutritious  and  grateful  to  an  inflamed  throat. 

The  Significance  of  Tonsillitis  in  Children, 

A  diagnosis  of  tonsillitis  or  quinsy  is  usually  thought  to  imply  that  we 
are  dealing  with  a  benign,  easy-going  condition.  That  the  reverse  is  true 
is  very  apparent  when  a  critical  inquiry  will  follow  the  termination  of  each 
and  every  case.  In  a  series  of  12  cases  of  follicular  tonsillitis  taken  at 
random  as  I  saw  them,  the  bacteriological  diagnosis  in  7  of  these  cases  was 
diphtheria. 

The  frequency  with  which  endocarditis  and  nephritis  are  seen  implies 
that  there  may  have  been  some  antecedent  disease  from  which  pathogenic 
bacteria  caused  the  valvular  heart  lesion,  or  possibly  a  nephritis.  The  fol- 
lowing case  will  illustrate  very  forcibly  the  dangers  of  the  so-called  ordinary 
tonsillitis : — 

A  girl,  24  years  old,  occupation  housemaid,  was  in  good  health  up  to  the  time  of 
illness.  She  was  exposed  to  cold  and  two  days  later  complained  of  pains  in  the 
body  and  rawness  in  the  throat.  A  physician  was  called  and  tonsillitis  diagnosed. 
The  usual  remedies  were  prescribed,  but  as  she  did  not  improve  she  was  sent  to  the 
hospital.  A  culture  taken  showed  the  presence  of  the  Klebs-Loefiler  bacilli.  While 
at  the  Willard  Parker  Hospital  symptoms  of  stenosis  appeared,  which  required 
intubation. 

Two  children  in  the  same  family  were  exposed,  and  on  learning  the  nature  of  the 
disease,  I  injected  an  immunizing  dose  of  antitoxin  of  500  units  into  each  child,  age 
7  and  10  years  respectively.  Tlie  older  boy  had  a  reddened  tonsil  and  I  believe  was 
suffering  with  a  premembranous  form  of  angina.  No  reaction  followed  the  injection 
of  antitoxin  and  both  boys  remained  well. 

The  housemaid  before  mentioned,  who  was  intubated  and  received  antitoxin, 
died  three  days  after  being  admitted  into  the  hospital.  A  study  of  her  case  shows 
two  interesting  things: — 

1.  An  apparently  mild  tonsillitis  may  frequently  be  a  follicular  form  of 
diphtheria,  wherein  the  crypts  or  lacunae  of  the  tonsil  are  the  seat  of  the  disease. 

2.  That  Klebs-Loeffler  bacilli  were  found,  by  bacteriological  examination,  hence 
the  diagnosis  of  follicular  diphtheria  was  correct.  The  disease  spread  downward 
from  the  tonsil,  causing  laryngeal  stenosis,  and  laryngeal  oedema,  necessitating  intu- 
bation, and  ending  fatally. 

Tlie  post-mortem  examination  showed  an  extensive  oedema  of  the  glottis  and 
infiltration  of  larynx.  Pseudo-membranes  were  also  present.  When  the  larynx  was 
incised,  large  quantities  of  pus  exuded  from  below. 

Another  point  worthy  of  note,  is  that  the  two  children  exposed  to  this  house- 
maid, one  of  them  having  an  angina,  the  other  remaining  normal,  were  immune  and  in 
perfect  health  after  receiving  500  antitoxin  units. 

Follicular  Tonsillitis,  or  Follicular  Catarrh. 

Follicular  catarrh  is  the  most  frequent  form  of  inflammation  of  the 
tonsils. 


432  DISEASES  OF  THE  NOSE  AND  THROAT. 

Bacteriology. — The  examination  of  the  purulent  plugs  of  follicular 
angina  reveals: — 

(a)  Staphylococcus. 

(h)  Streptococcus. 

(c)  Pneumococcus. 

Staphj'lococcus  angina  is  a  relatively  harmless  inflammatory  lesion 
passing  off  without  complications. 

The  streptococcus  variety  is  a  severer  type  of  disease  associated  with 
fever  and  glandular  enlargement.  This  disease  is  associated  frequently  with 
a  general  toxaemia  and  may  be  followed  by  nephritis  or  septicemia. 

The  pneumococcus  form  is  usually  ushered  in  with  a  chill  and  some- 
times runs  a  course  similar  to  that  of  pneumonia.  There  is  usually  a  red- 
ness and  swelling  of  the  tonsils,  lacunar  catarrh,  and  increased  secretion, 
which  agglutinates  and  shows  itself  at  the  follicular  openings  as  yellowish- 
white  spots. 

The  lymphatic  glands  at  the  angle  of  the  jaw  are  sometimes  enlarged 
and  tender  on  palpation. 

Croupous  Tonsillitis. 

This  is  a  severer  form  of  inflammation  than  the  one  above  described. 
It  involves  the  whole  structure  of  the  tonsil  and  most  especially  the  crypts. 
The  large  quantity  of  fibrin  which  is  poured  out  forms  a  distinct  pseudo- 
membrane.  It  is  very  difficult  to  differentiate  this  from  diphtheria.  A 
culture  should  be  taken  in  all  cases  (see  the  ''Diagnosis  of  Diphtheria**). 

We  cannot  dift'erentiate  this  disease  from  true  dij)litheria  clinically 
except  by  resorting  to  l)aetei'io]ogical  cultures. 

Ulcero-membranous  Tonsillitis. 

This  disease  was  first  described  by  Vincent^  who  maintained  that  it 
was  caused  by  a  fusiform  bacillus,  although  a  spirillum  was  found  asso- 
ciated with  it. 

Microscopically,  there  is  a  spindle-shaped  bacillus  along  with  spirilli. 
The  bacillus  does  not  stain  with  Gram.     A  clear  culture  is  hard  to  obtain. 

The  pseudo-membranes,  whitish  or  grayish  in  color,  are  easily  detach- 
able until  the  third  day,  when  the  ulcer  forms.  This  ulcer  corresponds 
to  the  portion  of  the  tonsil  occupied  by  the  pseudo-membrane.  Around  its 
edges  the  mucous  membrane  is  reddened.  The  accompanying  symptoms  are 
difficulty  in  swallowing,  fever,  anorexia,  headache,  and  swelling  of  the 
submaxillary  glands.  The  pseudo-membrane  docs  not  increase  when  this 
piece  of  membrane  is  detached.     The  ulcer  heals. 

It  resembles  croupous  tonsillitis  in  its  general  appearance.  It  is  often 
unilateral.     The  yellowish  exudation  seen  on  the  tonsil  greatly  resembles 

•  Arch.  International  de  Laryngologie,  1898,  No.  1. 


PHLEGMONOUS  TONSILLITIS.  433 

diphtheria.     It  is  a  superficial  necrosis,  and  when  this  tissue  is  wiped 
away  with  a  swab  bleeding  occurs. 

There  are  swollen  lymph  nodes  at  the  angle  of  the  jaw. 

This  disease  is  a  local  process  and  rarely  has  constitutional  symptoms 
accompanying  it. 

Prognosis. — The  prognosis  is  excellent. 

Treatment. — Gargle  with  bichloride,  1  to  2000,  or  with  a  weak  solution 
of  permanganate. 

Locally,  iodine,  or  3  per  cent,  peroxide  of  hydrogen  or  10  per  cent, 
nitrate  of  silver  solution,  can  be  repeated  in  twelve  hours  if  no  improvement 
is  noted. 

A  B 


Fig.  127. — Vincent's  Bacillus  Found  in  Ulcerative  Angina-  A,  Fusi- 
form bacillus  having  a  thickened  center  and  tapering  toward  both  ends. 
Also  spindle-shaped  bacilli.     B,  Fusiform  bacillus  having  spores.     (Original.) 

Phlegmonous  Tonsillitis  (Quinsy:  Peritonsillar  Abscess). 

This  form  of  angina  is  usually  caused  by  an  invasion  of  the  staphy- 
lococcus. 

When  the  cellular  tissue  surrounding  the  tonsil  is  infected  the  inflam- 
mation may  terminate  in  : — 

(a)  Eesolution. 

(h)  Abscess. 

It  is  one  of  the  rarer  forms  of  inflammatory  conditions  met  with  in 
children. 

Symptoms. — The  symptoms  arc  similar  to  those  of  follicular  tonsillitis. 
The  temperature  rises  to  101°  and  102°  F.    Sometimes  as  high  as  105°  F. 

The  child,  if  old  enough,  will  complain  of  pain  on  swallowing,  and 
at  times  it  may  be  impossible  to  open  the  mouth.    On  examining  the  throat 


434  DISEASES  OF  THE  NOSE  AND  THROAT. 

the  inflammation  can  be  seen.  There  is  a  marked  congestion  and  ced«ma 
involving  the  tonsils,  fauces,  and  uvula. 

Holt  reports  a  case  of  torticollis  several  days  before  the  diagnosis  of 
quinsy  was  established. 

Treatment. — Aconite  in  1-drop  doses,  repeated  every  one  or  two  hours 
for  the  first  day,  will  frequently  abort  the  disease.  Guaiacol  carbonate  given 
in  1  to  5-grain  doses  every  three  or  four  hours,  has  served  me  very  well  in 
some  instances. 


Throat  Spray. 


Local  Treatment. — Local  treatment  consists  in  spraying  the  throat 
with  a  1  to  2000  bichloride  of  mercury  solution  every  two  hours. 

An  ice-bag  over  the  neck  will  sometimes  relieve  inflammation.  The 
external  application  of  leeches  will  relieve  congestion.  When  fluctuation 
is  felt  the  pus  should  be  relieved  by  making  a  deep  incision  with  a  long, 
pointed  bistoury. 


Fig.  129.— Throat  Ice-bag. 

The  Danger  of  Hcemorrliage. — Laryngologists,  as  a  rule,  advise  great 
caution  in  operating  in  this  region  owing  to  the  large  number  of  blood- 
vessels located  there. 

After  the  incision  is  made  the  wound  should  be  enlarged  by  inserting 
a  polypus  forceps  or  an  artery  clamp  and  separating  the  blades.  By  this 
means  we  can  easily  evacuate  the  pus  and  do  not  run  the  risk  of  bleeding. 
I  am  indebted  to  Dr.  George  F.  Shrady  for  this  valuable  surgical  hint. 

Chronic  Hypertrophic  Tonsillitis. 

The  chronic  enlargement  of  the  tonsils  is  due  to  recurring  inflammatory 
attacks.  This  hypertrophy  comes  from  a  proliferation  of  the  lymphoid 
tissue  and  an  increase  in  the  connective  tissue  stroma. 


CHRONIC  HYPERTROPHIC  TONSILLITIS.  435 

Etiology. — It  is  usually  found  in  rachitic  and  subnormal  children. 
Bad  ventilation  and  improper  hygiene  are  among  the  prime  causes  of  this 
disease.  In  a  series  of  several  hundred  children  examined  by  me  in  one 
of  my  clinics  for  various  diseases,  90  per  cent,  suffered  with  enlarged 
tonsils.  All  of  these  children  lived  in  tenement  houses,  and  we  must  asso- 
ciate the  crowded,  ill- ventilated  apartments  with  the  poisoned  air  inspired 
and  its  resulting  throat  disease. 

Predisposing  causes,  such  as  rheumatism  in  the  parents,  have  been 
given  by  some  authors  as  causative  factors. 

Symptoms. — When  we  are  told  that  an  infant  snores  and  breathes  with 
its  mouth  open,  then  enlarged  tonsils  may  be  suspected  as  the  cause.  On 
the  other  hand  an  inspection  of  the  post-nasal  spaces  should  also  be  made 
to  eliminate  the  presence  of  adenoids  as  the  probable  cause  of  the  difficuH 
respiration. 

Deafness  can  rarely  be  attributed  to  enlarged  tonsils.  It  is  more  often 
caused  by  the  closure  of  the  Eustachian  tubes  due  to  adenoids.  The  nasal 
tone  of  voice  often  accompanies  enlarged  tonsils. 

Course. — Enlarged  tonsils  increase  during  childhood  and  remain  per- 
manently until  puberty  arrives,  when  they  usually  shrink  in  size  without 
treatment. 

Tlie  indications  for  the  removal  of  chronic  enlarged  tonsils  are:- — 

1.  Where  there  are  repeated  attacks  of  tonsillitis. 

2.  Where  there  is  inability  to  breathe  sufficiently  through  the  nose, 
with  snoring,  during  sleep. 

3.  Nasal  voice  and  deficient  articulation. 

4.  Deafness  and  attacks  of  earache. 

5.  Tendency  to  pigeon-breast. 

When  atiy  or  all  of  the  above  conditions  exist  then  a  guarded  opinion 
should  be  given  until  we  ascertain  whether  or  no  the  case  is  complicated  by 
adenoids. 

In  the  latter  cases  the  removal  of  the  tonsils  will  not  suffice  to  cure  the 
patient  until  the  rhino-pharynx  is  treated  for  the  removal  of  the  adenoids. 

There  are  few  conditions  met  with  in  children  which  are  more  satis- 
factory from  a  therapeutic  standpoint  than  the  operation  for  tonsils  and 
adenoids. 

Dangers. — Desire^  collected  20,000  tonsillotomies.  In  9  cases  bleeding 
took  place.  In  none  of  these  cases  was  it  fatal,  and  in  several  it  was  not 
serious. 

Lefferts^  lays  stress  on  the  ascending  pharyngeal  artery  as  being  one 
of  the  most,  if  not  the  most,  prolific  source  of  severe  bleeding  after  ton- 


*  Sajous's  Annual,  1891,  vols,  iv  and  v. 
'Archives  of  Laryngology,  vol.  iii,  p.  43. 


436 


DISEASE:'.  OF  THE  NOSE  AND  THROAT. 


sillotomy.  It  is  important  to  inquire  if  children  suffer  with  hcemopMlia 
(bleeders)  ;  in  such  cases  fatal  hemorrhage  will  frequently  occur.  I  have 
also  met  with  a  case  of  congenital  syphilis  in  which  a  serious  haemorrhage 
followed  a  tonsillotomy.  This  was  evidently  due  to  a  syphilitic  degeneration 
of  the  blood-vessels. 

The  Operation. — The  bistoury  is  rarely  or  never  used  for  this  opera- 
tion. Some  operators  use  a  wire  snare.  In  my  experience  the  adjustment 
of  a  snare  in  an  unruly  child  is  so  difficult  and  so  much  time  is  lost,  that 


Fig.  130.— The  Baginsky  Tonsillotome. 

it  is  not  practical.  My  preference  has  been  for  some  form  of  tonsillotome. 
The  Mackenzie  type  is  a  very  good  one.  The  Baginsky  tonsillotome  is  one 
of  the  best.  (See  illustration  Fig.  130.)  It  is  simply  a  sharp-bladed  guil- 
lotine and  can  be  very  easily  adjusted. 


Fig.  131. — The  Mackenzie  Tonsillotome. 


Haemorrhage  following  the  operation  need  not  cause  anxiety.  When, 
however,  liieniorrluge  follow.^,  then  adrenalin  chloride  solution  in  full 
strength  (Viooo)  should  be  liljerally  used.  It  may  be  applied  in  the  form 
of  a  spray  or  by  means  of  a  cotton  pledget  soaked  with  the  solution.  The 
galvano-cautery  or  the  local  api)lication  of  peroxide  of  hydrogen  is  fre- 
quently useful.  In  older  children  small  pieces  of  cracked  ice  or  ice  cream 
will  control  bleeding. 

The  Use  of  an  Anaesthetic.^ — The  local  application  of  a  10  per  cent, 
cocaine  solution  has  been  recommended  by  a  great  many  authors.  I  have 


Read  chapter  on  "Anaesthesia  in  Ciiildren,"  page  930. 


TUBERCULOSIS  OP'  THE  TONSILS.  437 

used  cocaine  in  children  and  have  seen  very  bad  constitutional  effects,  such 
as  severe  cardiac  depression,  nausea,  and  frequently  vomiting  following  its 
use. 

Spraying  the  tonsils  with  ethyl  chloride  for  several  seconds  produces 
local  anesthesia.  It  is  very  valuable  with  sensitive  children.  In  some 
instances  a  few  whiffs  of  chloroform  are  necessary  to  have  the  child  com- 
pletely under  control. 

Chloroform  is  very  rajiid.  l)ut  it  must  be  cautiously  given. 

It  is  advisable  to  operate  before  feeding,  so  that  in  the  event  of  vom- 
iting food  should  not  be  expelled. 

It  is  advisable  to  thoroughly  swab  the  mouth,  pharynx,  and  tonsils 
with  an  antiseptic  solution  before  the  operation.     For  this  purpose  use: — 

Listerine   1  part 

Sterile  water  5  parts 

Or  Dobell's  solution. 

Apply  with  a  cotton  swab. 

Normally  pathogenic  bacteria  abound  in  the  mouth  and  post-nasal 
spaces.  After  a  tonsillotomy  a  white  croupous  deposit  resembling  diph- 
theria will  be  seen.  This  should  not  be  considered  a  diphtheritic  infection 
unless  the  Klebs-Loeffler  bacillus  can  be  demonstrated. 

Owing  to  the  raw  surfaces  following  a  tonsillotomy  the  greatest  care 
must  be  used  to  isolate  the  patient  from  infectious  diseases.  Scarlet  fever 
and  diphtheria  will  gain  access  much  easier  soon  after  this  operation  is 
performed. 

Tuberculosis  of  the  Tonsils, 

Schlesinger  states  (Forts,  der  Med.  Pediatrics)  that  *'up  to  the  present 
time  the  parallelism  between  advanced  tuberculosis  of  the  lungs  and  tuber- 
culosis of  the  tonsils,  as  also  that  between  mild  or  passed  tuberculous 
processes  of  the  lungs,  with  the  escape  of  the  tonsils,  has  only  been  demon- 
strated in  the  case  of  adults,  but  has  not  been  observed  in  children.  He  was 
able  to  confirm  this  parallelism  also  in  children,  having  found  12  cases  of 
tuberculosis  of  the  tonsils  in  13  of  florid  tuberculosis  of  the  lungs.  The 
diagnosis  of  tonsillar  tuberculosis  is  hardly  possible  microscopically,  for  the 
reason  that  tubercular  ulcerations  are  only  found  very  rarely  on  their 
surface;  neither  were  the  tonsils  hypertrophied  without  exception,  but 
were  found  pale  and  firm  in  nearly  two-thirds  of  the  cases.  In  9  cases 
examined  for  the  purpose,  the  tonsils  were  found  to  be  affected  bilaterally, 
although  not  with  equal  intensity.  As  to  the  relation  between  tuberculosis 
of  the  lymphatic  glands  of  the  neck  and  that  of  the  tonsils,  in  9  cases  the 
ar.thor  found  that  the  tonsils  were  healthy  in  2.  He  inclines,  therefore,  to 
the  view  that  a  primary  tonsillar  tuberculosis  is  not  to  be  taken  for  granted 
in  all  cases;  but  we  must  take  into  account  the  possibility  of  their  infection 


438  DISEASES  OF  THE  NOSE  AND  THROAT. 

by  cheesy  cervical  glands,  by  means  of  the  return  flow  of  lymph.  The 
author  finds  some  support  for  this  view  from  the  fact  that  in  these  cases 
the  recent  tubercles  are  situated  at  the  base  of  the  tonsils  away  from  the 
crypts/' 

L.  Kingsford^  examined  the  tonsils  removed  post-mortem  from  17 
children,  varying  in  age  from  four  months  to  9  years.  All  showed  cervical 
glandular  enlargement,  and  in  11  it  was  obviously  tuberculous.  Of  the 
17,  tonsillar  deposits  were  found  in  7,  but  only  3  exhibited  any  naked-eye 
tuberculous  changes.  Of  these  3, 1  showed  ulceration,  a  second  scarring,  and 
a  third  a  sebaceous  focus.  Practically  all  the  17  were  cases  of  secondary 
infection  from  either  blood  or  sputum.  The  parts  of  the  tonsils  which 
were  the  seats  of  the  lesions  were  usually  the  lymphoid  follicles  not  far 
from  the  epithelial  surface,  but  it  is  not  possible  to  trace  bacilli  in  from 
the  crypts  or  surface  of  the  organs.  The  author  believes  it  possible  that 
infection  may  work  through  healthy  tonsils  to  the  cervical  glands,  the 
former  becoming  infected  at  a  later  period. 

Tuberculous  tonsillitis  is  a  very  rare  affection.  The  tonsils  are  rarely 
if  ever  the  site  of  primary  inoculation  in  pulmonary  tuberculosis. 

Adenoid  Vegetations? 

Adenoid  vegetations  consist  of  a  hypertrophy  of  the  adenoid  tissue 
which  exists  normally  in  the  naso-pharynx. 

Pathology. — In  a  less  severe  form  the  growth  may  be  confined  to  the 
roof  of  the  naso-pharyngeal  cavity.  In  severe  forms  the  vegetations  are 
very  numerous,  irregular  in  shape,  and  extend  from  the  roof  of  the  cavity 
to  the  lateral  walls.  They  grow  from  the  fossa  of  Eosenmuller.  They 
frequently  cover  the  orifices  of  the  Eustachian  tubes.  There  are  fre- 
quently, according  to  Hall,  between  the  enlarged  pharyngeal  and  faucial 
tonsils,  and  sometimes  the  adenoid  tissue  at  the  base  of  the  tongue,  the 
so-called  lingual  tonsil. 

The  difference  between  vegetations  and  an  enlarged  tonsil  is  that  the 
tonsil  has  a  great  amount  of  connective  tissue  due  to  the  irritation  produced 
by  the  passage  of  food,  whereas  the  vegetations  by  their  situation  are  pro- 
tected from  these  injurious  influences. 

Symptoms. — The  "adenoid  habitus,"  the  pinched  expression  of  the 
nose  and  the  long  drawn  face,  are  very  typical.  There  is  frequently  lateral 
narrowing  of  the  alveolar  arch  and  prominence  of  the  upper  incisor  teeth. 
Owing  to  the  interference  of  respiration  the  mouth  is  kept  open.  The  lips 
are  swollen  and  thick. 


» The  Lancet,  January  9,  1904. 

•  For  "Congenital  Adenoids,"  see  clinical  history  on  page  55. 


PLATE  XIII 


# 


Chronic  Enlarged  Tonsils  and  Associated  Congested  Throat,  very  frequently 

seen.      (Original.) 


A  case  of  Oraiuihir   Pharyngitis.     Large   masses   could   bo   palpated   in   the 
rhino-pharynx.     (Original.) 


ADENOID  VEGETATIONS. 


439 


Spicer  has  directed  attention^  to  the  distention  of  the  transverse  nasal 
vein  as  one  of  the  indications  of  the  presence  of  adenoids. 

Deafness. — Deafness  is  frequently  caused  by  the  presence  of  adenoids. 
The  amount  of  interference  caused  by  the  adenoids  will  depend  on  the 
relation  of  the  Eustachian  tube  orifice  to  the  vault  of  the  pharynx.  If  the 
orifice  be  situated  high  up,  a  small  amount  of  growth  will  occlude  it  and 
cause  auditory  trouble.  When  the  orifice  is  situated  low  down  there  may 
be  extensive  vegetations  without  the  Eustachian  tube  being  implicated.' 
The  voice  has  a  muffled 
sound  with  a  nasal  twang. 
The  letters  m,  n,  and  ng 
cannot  be  pronounced. 
Stuttering  or  stammering 
can  frequently  be  cured  if 
vegetations  are  removed; 
the  explanation  being  that 
the  spasmodic  actions  of  the 
muscles  of  the  throat  are 
due  to  reflex  irritation. 
Earache  frequently  accom- 
panies adenoids. 

Bed  wetting  is  usually  as- 
sociated with  adenoids. 
Among  several  hundred 
children  examined  in  the 
children's  service  of  a  large 
dispensary,  it  was  rare  to 
find  a  case  of  enuresis  that 
was  not  associated  with 
adenoid  vegetation. 

Diagnosis. — The  mouth  breathing,  the  snoring  at  night,  the  adenoid 
face,  are  in  themselves  sufficient  to  establish  a  diagnosis.  To  examine  the 
rhino-pharynx  for  the  presence  of  adenoids,  have  the  nurse  seated  with  the 
child  on  her  lap,  firmly  pinning  the  child's  feet  between  her  knees.  While 
the  right  hand  confines  the  child's  arms,  the  left  hand  is  used  to  support 
the  head.  The  physician  should  then  separate  the  jaws  with  the  aid  of  a 
mouth  gag  and  explore  the  post-nasal  ^pace  with  his  index  finger.  In  the 
absence  of  a  gag  a  clean  cork  or  the  handle  of  a  spoon  protected  by  gauze 
can  be  used  to  separate  the  jaws. 

If  the  child  is  very  unruly  it  is  wiser  to  pin  a  sheet  securely  across 
tlie  arms  and  examine  in  the  dorsal  position. 


f 


% 


Fig.  132. — ^Typical  Adenoid  Face  in  a  Cretin. 
(Original.) 


Mjritish  Medical  Journal,  1887,  p.  459. 
^  Sajous's  Annual,  1888,  vol.  iii,  p.  278. 


440 


DISEASES   OF   THE   NOSE   AND   THROAT. 


The  i)hysician  can  best  niako  the  exaiiiiiiation  by  standing  directly 
behind  the  child. 

In  making  a  diagnosis  of  adenoids  in  infants^  we  must  naturally  depend 
to  a  great  extent  upon  the  inability  to  nurse  properly  and  noisy  mouth 
breathing.  However  many  other  cases  of  noisy  mouth  breathing  should  be 
excluded.    These  briefly  mentioned  are : — 

1.  Congenital,  as : — 

Diminution  in  size  or  occlusion  of  one  or  both  nostrils. 
Highly  arched  palate  or  deformity  of  soft  palate. 
Distortion  of  cervical 

vertebra\ 
Atelectasis. 

2.  Constitutional,  as:  — 

Syphilis. 
Lymphatism. 
Tuberculosis. 
Lithasmia. 

3.  Other  conditions,  such  as : — 

Acute  rhinitis. 
Eectopharyngeal        ab- 
scess. 
Disturbances   of    diges- 
tion. 
Paralysis  of  soft  palate 

or  pharynx. 
Diphtheria,      especially 
nasal. 

These  have  to  be  carefully  considered.  Those  conditions  may  exist 
with  adenoids,  l)ut  when  alone  may  cause  symptoms  similar  to  those  occa- 
sioned by  the  presence  of  tlie  hypertrophied  tissue,  so  an  operation  may 
not  result  in  the  promised  cure.  In  infants  the  examining  finger,  on 
account  of  its  size,  is  out  of  the  question,  and  the  rhinoscopic  mirror  cannot 
be  employed.  To  be  absolutely  certain  the  curette  must  establish  the  diag- 
nosis. 

Prognosis. — The  disorders  arising  from  the  presence  of  adenoids  are: 
Repeated  attacks  of  coryza,  chronic  rhinitis,  arrest  of  nasal  development, 
nasal  stenosis,  and  mouth  breathing,  with  the  associated  mental  listlessness. 
There  is  a  tendency  to  bronchitis,  to  spasmodic  croup  and  asthma.  Children 
with  adenoids  usually  have  very  poor  appetites.     There  is  an  associated 


Fig.  133.— Digital  Method  of  Exploring 

the  Rhino-pharynx  for  Adenoids. 

(Original.) 


^Abstract  of  a  paper  read  by  Dr.  Herman  Jarccky.  April,  1904,  Meeting  of  the 
Society  of  Alumni  of  Charity  (City)   Hospital,  New  York. 


ADENOID  VEGETATIONS.  441 

gastric  catarrh.  Some  authors^  state  that  measles,  scarlet  fever,  and  ear 
troubles  are  more  frequently  found  in  children  where  adenoids  exist.  Their 
presence  is  therefore  a  menace  and  they  certainly  invite  infection. 

Treatment. — Meyer,  of  Copenhagen,  certainly  deserves  the  credit  for 
the  plan  of  treatment  used  in  these  cases.  The  following  method  has  been 
used  by  me  for  some  time : — 

It  is  best  to  use  an  aiuestkeiic,  as  most  children  with  adenoids  are  of  a 
neurotic  temperament. 

A  rapid  anaesthetic  in  children  is  chloroform.  Some  authors  advise 
the  use  of  nitrous  oxide  followed  by  ether  as  the  best  2iieans  of  producing 
anaesthesia.  Deep  anaesthesia  is  uncalled  for,  as  in  that  condition  the  cough 
reflex  would  be  abolished.  It  is  better  to  do  the  operation  completely  rather 
tlian  put  a  child  to  the  pain  and  discomfort  of  repeated  sittings.  Two  or 
more  sittings  may  be  necessary  if  tl:e  child  is  not  anaesthetized.  The  evening 
before  the  operation  a  1-graiu  dose  of  calomel  or  a  wineglass  of  citrate  of 
magnesia  has  a  beneficial  effect  on  the  bowels.  The  position  of  the  child 
during  the  operation  is  of  great  imj^ortance.  Some  operators  prefer  the 
head  over  the  end  of  the  table.  Butlin-  says  the  patient  should  lie  on  the 
side  with  the  thighs  flexed,  the  head  a  little  forward  on  a  low  pillow. 

The  Operation. — The  Gottstein  curette  or  its  modification  is  best 
adapted  to  work  in  the  antero-posterior  diameter  of  the  naso-pharynx.  Th.e 
Lowenberg  forceps  or  its  modification  is  used  to  grasp  the  mass  and  is 
preferred  l)y  many  operators. 

AYith  the  curette  the  portion  removed  is  ai)t  to  be  lost  and  might  even 
drop  into  the  larynx,  although  it  is  the  safest  instrument  to  use  with  very 
young  children.  The  best  type  of  forceps  is  the  Graedle  or  its  modification 
by  Concannon.  This  foi'ceps  lias  an  extensive  cutting  edge,  hence  tearing 
is  unnecassary. 

Operating  ^yiUlout  an  Ancvsthctic. — The  child  should  l)e  placed  in  an 
upright  position  and  held  l)y  an  assistant.  A  mouth  g:ig  is  used,  and  the 
closed  forceps  is  introduced.  The  forceps  is  tl:en  opened  widely  and 
j)r('ssed  well  upward  and  behind.  The  mass  is  seized  and  the  force})s  with- 
drawn. The  finger  sliould  always  be  introduced  to  ha  sure  of  the  location 
and  extent  of  any  remaining  masses.  The  latter  can  be  removed  with  the 
finger,  curette,  or  with  smaller  forceps. 

If  the  Gottstein  curette  is  used  it  should  be  carried  well  up  into  the 
vault,  carrying  the  soft  palate  forward ;  then  it  should  be  brought  down 
witli  a  bold  sweep,  to  the  vault  of  the  pharynx.  The  steel  nail  is  frequently 
advised  by  some  operators  as  a  means  of  removing  adenoids.  In  spite  of  the 
most  careful  treatment^  adenoids  will  frecpiently  recur. 


'  Centralblatt.  vol.  i,  p.  278. 

Mxanrct,  vol.  i,  1893,  p.  .303. 

'W.  K.  Simpson    February   13,   1002. 


442  DISEASES  OF  THE  NOSE  AND  THROAT. 

Hcemorrhages  After  Operation. — -The  local  application  of  diluted 
peroxide  of  hydrogen,  or  adrenalin  solution  1  to  lUOU,  is  sufficient  to  control 
any  ordinary  hemorrhage.  If,  however,  it  is  a  case  of  haemophilia  or  pro- 
fuse bleeding,  then  the  subcutaneous  injection  of  30  cubic  centimeters 
sterile  horse  serum  into  the  thigh  or  abdomen  will  control  the  bleeding. 

The  After-treatment. — The  after-treatment  will  consist  in  giving  syrup 
of  hypophosphites,  i/^  drachm,  two  or  three  times  a  day,  or  the  tincture  of 
iron,  given  in  5  to  20-drop  doses  three  times  a  day,  will  have  a  good  local 
and  constitutional  effect. 

The  application  of  a  diluted  solution  of  iodine  is  frequently  useful : — - 

R   Iodine 2  grains 

Potass,    iodide    10  grains 

Glycerine    1  ounce 

M.     Sig. :     To  be  applied  witli  a  cotton  swab  every  two  or  three  hours. 

Codliver-oil  and  malt  extract  are  among  the  restoratives  indicated  for 
the  after-treatment.  The  most  important  part  of  the  after-treatment  con- 
sists in  the  strict  application  of  hygienic  measures.  The  child  should  be 
placed  in  a  room  in  which  there  is  fresh  air,  windows  open  night  and  day. 
If  a  child  is  old  enough  we  should  teach  it  how  to  breathe.  Out-of-door 
exercise  should  be  insisted  upon.  Deep  inspiration  and  expiration,  and 
pulmonary  gymnastics  are  just  as  important  as  attention  to  the  food.  Milk, 
meat,  eggs,  cereals,  and  fruits  should  be  ordered,  depending  on  the  age  and 
requirements  of  the  case. 

Ketkopiiartxgeal  Abscess   (Retropharyngeal  Lymph  Adenitis). 

This  condition  may  be  due  to  mechanical  irritation  or  to  direct  infec- 
tion.    The  most  common  forms  met  with  in  children  are  evidently  due  to : — 

1.  Local  infection. 

2.  Abscess  caused  Ijy  a  tubercular  infection  or  where  caries  of  the 
cervical  vertebrae  exists.  This  latter  condition  we  meet  in  older  children. 
It  is  usually  a  sequel  to  the  specific  infections,  and  may  follow  scarlet  fever, 
measles,  or  diphtheria.  It  is  most  frequently  associated  with  influenza  and 
tuberculosis.  Eachitic  and  syphilitic  children  are  predisposed  to  this  dis- 
ease.    Catarrhal  affections  of  the  upper  air  passages  also  invite  this  disease. 

Pathology. — The  retropharyngeal  lymph  nodes  are  described  (Simon) 
as  forming  a  chain  on  each  side  of  the  median  line  between  the  pharyngeal 
and  prevertebral  muscles;  these  undergo  atrophy  after  the  third  year. 
Sometimes  adenoids  will  cause  a  swelling  of  the  glands,  giving  rise  to  fever, 
but  they  will  not  suppurate.  At  other  times  the  swelling  of  the  retro- 
pharyngeal lymph  nodes  will  be  associated  with  external  cervical  adenitis. 
It  is  important  to  recognize  this  condition  owing  to  the  serious  nature  of 
the  disease. 


RETROPHARYNGEAL  ABSCESS. 


443 


Symptoms. — This  affection  usually  develops  very  suddenly;  the  infant 
will  refuse  the  breast  or  have  trouble  in  swallowing.  The  food  is  most 
commonly  regurgitated  through  the  nose.  Such  infants  will  have  labored 
mouth  breathing.  The  head  is  thrown  back,  there  is  severe  dyspnoea,  occa- 
sionally asphyxia — laryngeal  stenosis  due  to  pressure  of  the  abscess  on  the 
larynx,  interfering  with  respiration.  There  is  a  peculiar  snoring  sound. 
With  the  index  finger  in  the  throat  the  soft  fluctuating  tumor  can  be  felt. 
On  examining  the  throat  with  a  good  light  the  bulging  of  the  pharyngeal 
wall  will  be  noticed. 

The  temperature  will  range  from  102°  to  103**  F..  sometimes  higher. 

Diagnosis. — The  diagnosis  should  be  made  with  the  finger,  by  a  careful 
palpation  of  the  post-nasal  and  pharyngeal  spaces.  Mouth  breathing  due 
to  adenoids  will  not  cause  sudden  symptoms  of  suffocation.  The  sudden- 
ness of  interference  with  respiration  points  to  the  development  of  an  abscess. 
The  following  cases  will  illustrate  this  condition: — 

Case  I. — An  infant  about  fifteen  months  old  was  brought  to  my  office  by  Dr.  J. 
Martinson.  The  history  was  loss  of  appetite,  regurgitating  of  food  through  the  nos- 
trils, mouth  breathing,  and  bulging  of  the  pharyngeal  wall.  Temperature,  101°  F. 
Cervical  glands  enlarged.  The  diagnosis  of  retropharyngeal  abscess  was  made.  An 
incision  made  in  the  abscess  liberated  the  pus.  The  abscess  cavity  was  cleansed 
with  a  1  to  2000  bichloride  solution.     The  child  recovered. 

Case  II. — A  nursing  infant,  less  than  1  year  old,  seen  with  Dr.  J.  Brandeis,  suf- 
fered with  retropharyngeal  abscess.  The  treatment  consisted  in  hot  fomentations. 
When  fluctuation  was  detected,  an  incision  was  made  with  a  curved  bistoury;  the 
lower  half  of  the  blade  was  protected  with  cotton.  After  the  incision  the  wound 
was  enlarged  by  introducing  and  separating  the  blades  of  a  polypus  forceps.  The 
child  recovered. 


TSCC'oi.     1 8 


14- 


15 


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19 


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Fig.  134. — Temperature  Chart  from  a  Case  of  Retropharyngeal  Abscess. 

(Oiiginal.) 


444  DISEASES  OF  THE  NOSE  AND  THROAT. 

Treatment. — Some  children  require  local  applications.  Antiphlogis- 
tine  is  a  convenient  local  application  until  suppuration  is  established.  Flax- 
seed poultices  are  sometimes  well  borne. 

No  time  should  be  lost  if  pus  is  present.  The  abscess  cavity  should 
be  opened  and  the  pus  liberated.  To  prevent  the  pus  flowing  into  the 
trachea,  it  is  best  to  keep  the  head  well  forward.  The  use  of  a  gag  is  not 
necessary  if  the  tongue  is  depressed  and  the  incision  made  with  a  small- 
bladed  knife  similar  to  a  tenotome.  After  the  pus  is  evacuated  the  parts 
should  be  cleansed  with  a  1  per  cent,  carbolic  solution  or  a  1  to  2000 
bichloride  solution,  and  the  wound  treated  on  general  aseptic  principles. 
Eestorative  treatment  will  consist  in  giving  codliver-oil,  hypophosphites, 
and  last,  but  not  least,  food  and  fresh  air. 

Spasmodic  Lakyxgitis  (Catariuial  Cuorr:     Spasmodic  Croup). 

This  form  of  acute  catarrhal  spasm  was  first  described  by  Goodhart. 
The  disease  is  simply  an  acute  catarrhal  inflammation  associated  with  a 
severe  spasm  of  the  larynx.  Infants  under  six  months  of  age  are  rarely 
affected,  and  until  5  years  the  disease  is  most  common.  It  occurs  as  fre- 
quently in  well-nourished  as  in  frail  rachitic  children. 

Catarrhal  or  spasmodic  croup  is  frequently  the  result  of  hypersecretion 
in  the  naso-pharynx.  When  croup  appears  suddenly  it  should  not  he  feared, 
especially  so  if  the  child  was  well  during  the  day.  It  simply  results  from 
post-nasal  secretions  accunuil:iting  while  the  child  lies  on  its  back.  Such 
croupous  attacks  will  always  yield  to  a  good  emetic  dose  of  syrup  of  ipecac. 
Such  children  while  awake  suffer  from  the  irritation  of  the  secretion  and 
swallow  the  same  by  day.  A  point  to  remember  in  this  connection  is  that 
croup  which  is  fatal  or  serious  comes  on  very  sloivly  and  cannot  be  per- 
manently benefited  by  giving  an  emetic. 

Symptoms. — The  symptoms  are  similar  to  tliose  of  laryngeal  diph- 
theria. It  is  at  times  very  difficult  to  differentiate  catarrhal  spasm  of  the 
larynx  from  diphtheritic  ci'oup.  It  is  frequently  found  in  infants  with 
adenoid  vegetations  and  post-nasal  catarrh.  An  inflimed  uvula,  diseased 
tonsils,  and  pharyngeal  catarrh  are  among  the  contributing  factors.  The 
mucous  membrane  is  red  and  swollen.  At  first  it  is  dry,  but  afterward  it  is 
covered  with  a  watery  mucous  secretion.  The  catarrh  may  begin  in  the 
subglottic  portion  of  the  larynx  and  may  be  attended  by  some  mucous 
oedema.  It  usually  follows  catarrh  of  the  nose  and  pharynx,  or  it  may 
be  an  extension  of  the  disease  from  the  bronchi. 

Children  suffering  from  this  form  of  croup  will  usually  have  repeated 
attacks  of  the  same.  The  slightest  exposure  to  cold  and  irritation  by  dust 
are  among  the  exciting  causes. 

Alter  an  attack  of  rhinitis  lasting  one  or  more  days,  the  child  will 
suddenly  awaken  at  night  with  a  hoarse,  barking  cough  and  the  face  will 


SPASMODIC  LARYNGITIS.  445 

be  extremely  congested.  The  attack  terminates  by  a  long,  noisy,  high- 
pitched  inspiration. 

On  inspiration  we  note  deep  recession  of  the  suprasternal  fossa,  the 
supraclavicular  spaces,  and  the  epigastrium.  There  is  also  depression  of 
the  intercostal  spaces  and  the  walls  of  the  chest.  The  pulse-rate  will  be 
greatly  accelerated.  The  temperature  rarely  rises  over  102°.  F.,  although 
in  some  instances  it  may  reach  103°  F.  Owing  to  the  dyspnoea,  children 
will  usually  gasp  and  try  to  sit  up.  The  forehead  and  sometimes  the 
whole  body  will  be  covered  with  large  beads  of  perspiration  after  an  attack 
of  laryngeal  spasm. 

Prognosis. — This  is  invariably  good.  A  point  to  remember  is  that 
when  croup  appears  suddenly,  it  is  of  a  mild  type  resulting  from  catarrhal 
trouble.  The  dangerous  form  of  croup  comes  on  verij  slowly,  and  in  this 
type  we  must  always  look  for  diphtheria  as  a  causative  factor. 

Treatment. — In  the  treatment  of  diseases  affecting  the  air  passages  we 
aim,  roughly  speaking,  at  two  things: — 

First. — To  relieve  the  cough. 

Second. — To  cure  the  disease. 


/ 
i'lg.  135.^ — Oil  Atomizer. 

Local  Theatment. 

B  Menthol  5  parts 

Alboline 100  parts 

Or:— 

IJ  Menthol  5  parts 

Paroleine 100  parts 

Either  of  the  above  solutions  can  be  used  in  the  form  of  a  spray  every 
two  or  three  hours.  This  lubrication  soothes  the  mucous  membrane. 
Guaiacol,  2  per  cent,  solution,  dissolved  in  alboline,  can  also  be  used. 


446 


DISEASES  OF  THE  NOSE  AND  THROAT. 


IJ  Balsam  of  Peru Vi    drachm 

Oil  of  eucalyptus '/,    drachm 

M.  Sig.:  Dissolve  in  2  drachms  of  alcohol.  A  teaspoonful  into  a  pint  of 
boiling  water,  to  be  used  in  the  form  of  a  spray,  by  means  of  a  steam  atomizer. 
(Fig.  136.) 

When  a  tubercular  condition  is  suspected,  creosote  may  be  added  to  the 
steam  spray  with  marked  benefit. 


Fig.    136. — Steam    Atomizer. 

Directions  for  Using  a  Steam  Atomizer. — Put  the  liquid  to  be  atomized 
in  the  cup  D.  Fill  the  boiler  F  about  one-half  full  of  water.  Fill  the 
lamp  I  with  alcohol  (use  nothing  but  alcohol  in  the  lamp),  and  after 
lighting  it,  place  it  under  the  boiler.  As  soon  as  the  water  boils  the  medi- 
cated steam  will  be  thrown  out  through  the  tube  E,  and  can  be  inhaled 
through  the  shield  A. 

Intralaryngeal  injections  in  the  treatment  of  diseases  in  the  bronchi 
and  larynx  have  been  used  many  years. 

As  early  as  1853  Thompson  described  a  glass  and  silver  syringe  for 
this  purpose.  The  injection  was  made  through  the  glottis  into  the  cavity 
of  the  larynx  and  not  injected  under  the  mucous  membrane.  This  injected 
fluid  passes  into  the  larynx  and  trachea,  and  readily  enters  the  larger 
bronchi. 

Local  applications  of  iodine  and  glycerine  are  frequently  valuable: — 

I^  Iodine 3  grains 

Glycerine  1  ounce 

Kali   iodid 5  grains 

M-     Sig.:      Apply  with  a  cotton  swab,  on  larynx.     Once  daily. 


SPASMODIC  LARYNGITIS. 


447 


When  this  catarrh  persists,  a  single  application  of  the  following  will 
frequently  abort  an  acute  attack: — 

IJ  Argenti  nitric 10  grains 

Aqua  destillata 1  ounce 

M.     Sig.:      Apply  cautiously  over  the  larynx. 

Emetics. — The  most  rapid  method  of  relieving  catarrhal  accumulations 
is  in  giving  an  emetic.  The  choice  of  the  same  depends  on  individual 
experience.  A  safe  and  harmless  emetic,  quite  rapid  in  action,  is  a  tea- 
spoonful  of  syrup  of  ipecac.  The  same  dose  may  be  repeated  in  half  an 
hour  if  not  effectual.  Syr.  scillae  comp.,  commonly  known  as  Cox's  hive 
syrup,  in  teaspoonful  doses,  is  also  a  mild  drug,  producing  emesis.  Mustard 
water  and  sulphate  of  zinc  are  also  useful.  Tartar  emetic  in  ^/^Q-grain 
doses,  gradually  increased,  is  valuable.  My  favorite  emetic  is  sulphate  of 
copper,  1-grain  doses,  with  Vj  ounce  or  less  of  water.  This  usually  pro- 
duces an  instantaneous  effect. 

When  children  are  obstinate  and 
wOl  not  swallow,  a  Vgo-grain  or  V25- 
grain  tablet  of  apomorphia,  given 
hypodermically,  may  be  repeated  in 
ten  or  fifteen  minutes  if  necessary. 
This  is  a  convenient  and  rapid 
means  of  producing  emesis. 
Emesis  should  not  be  repeated 
oftener  than  once  in  twenty-four 
hours,  and  then  always  with  due  re- 
gard to  the  condition  of  a  child. 

Inhalations  of  steam  impregnated 
with  turpentine  or  pine  needle-oil 
have  served  me  very  well.  Eor  pro- 
ducing this  steam  a  croup  kettle  or 
a  steam  atomizer  may  be  used. 

The  steam  loosens  the  viscid  se- 
cretion and  can  be  used  every  hour 
or  less  often,  depending  on  the 
urgency  of  the  case.  Fig.  137.— Croup  Kettle. 


Foreign  Bodies  in  the  Larynx. 

Foreign  bodies  such  as  fish-bones  or  particles  of  food  are  occasionally 
aspirated  into  the  larynx,  causing  coughing  and  irritation.  In  some  cases 
laryngeal  stenosis  and  symptoms  of  asphyxia  result.  No  time  should  be  lost 
in  commencing  treatment,  owiug  to  the  danger  of  suffocation. 


448  DISEASES  OF  THE  NOSE  AND  THROAT. 

The  hypodermic  injection  of  apomorphia  (V50  grain)  until  emesis 
is  produced,  or  syrup  of  ipecac,  several  teaspoonfuls  given  by  mouth,  will 
occasionally  dislodge  the  foreign  body.  If  this  is  not  successful  a  laryn- 
gologist  should  be  sent  for.  A  physician  who  is  inexperienced  with  the 
larynx  should  refrain  from  prolonged  attempts  to  dislodge  the  foreign  body, 
as  in  most  cases  only  harm  can  result  therefrom.  If  asphyxia  threatens, 
tracheotomy  should  be  performed.  Those  experienced  with  intubation 
should  first  try  the  effects  of  the  large  caliber  tube  known  as  the  foreign 
body  tube  (see  chapter  on  'Tntubation*'). 

Coughs  of  Reflex  Origin. 
Night  Cough. 

A  very  troublesome  form  of  cough  is  frequently  heard  at  night.  The 
history  given  is  that  the  child  is  quite  well  during  the  day,  but  has  a  dis- 
tressing cough  at  night. 

The  position  of  the  child  on  its  back  permits  naso-pharyngeal  accu- 
mulations to  stagnate,  hence  this  cough  occurs  when  the  child  is  on  its 
back.  Very  young  children  do  not  expectorate  nor  can  they  clean  the 
nose. 

Diagnosis. — A  history  of  cough  at  night  only  points  to  naso-pharyn- 
geal disease.  As  a  rule  adenoids  and  chronic  tonsillitis  or  pharyngitis 
should  be  suspected.  The  absence  of  fever  and  the  freedom  from  cough 
during  the  day  indicates  a  local  catarrh  which  gravitates  when  the  child 
is  on  its  back. 

Treatment. — If  adenoids  are  present  they  should  be  removed.  Naso- 
pharyngeal catarrh  should  be  treated  by  local  applications  of  V2  P^r  cent,  of 
iodine  and  glycerine  solution.  The  naso-pharynx  should  be  washed  by  means 
of  a  douche  every  morning  and  evening.  A  weak  solution  of  boracic  acid  or 
bicarbonate  of  soda  is  very  serviceable.  In  persistent  catarrh  codliver-oil 
should  be  given. 

Spasmodic  Cough  (  Pseudo-pertussis )» 

I  have  previously  described  a  cough  which  occurs  in  children  having 
catarrh  of  the  upper  air  passages;  sometimes  this  night  cough  is  paroxysmal 
in  character  and  the  spasm  resembles  whooping-cough. 

Cause. — The  accumulation  of  the  mucus  in  the  region  of  the  arytasnoids 
and  the  vocal  cords  sets  up  a  spasm  of  the  glottis,  resulting  in  attacks  of 
suffocation. 

Symptoms. — A  hoarse  or  barking  cough,  appearing  in  spasms  with  an 
interval  of  rest,  is  usually  heard.  The  cough  is  frequently  followed  by  vom- 
iting.    The  temperature  is  rarely  above  normal. 


coucHS.  449 

Diagnosis.- — The  absence  of  the  cough  by  day  and  tJie  appearance  of 
the  cough  in  spasms  when  the  infant  is  pkiced  on  its  back,  always  points 
to  a  local  throat  condition  of  a  non-inflammatory  character. 

Treatment. — Eemove  the  cause  if  any  is  apparent.  Locally,  astrin- 
gents are  indicated.  Eestorative  treatment,  consisting  of  iron  and  Fowler's 
solution,  will  sometimes  permanently  benefit  the  .child. 

Useless  Cough. 

Thompson  and  MacCoy,  of  Philadelphia;  Francis  Warner,  of  London, 
and  Emil  Mayer,  of  New  York,  describe  an  irritating  hacking  cough  in 
children.  Such  children  do  not  suffer  with  fever,  but  have  a  poor  appetite, 
are  thin  and  irritable.  Warner  studied  a  series  of  23,000  children  in 
schools,  and  he  attributes  this  condition  not  to  peripheral  irritation,  in- 
testinal worms,  nor  to  any  disease  of  the  tonsils  or  pharynx,  but  to  un- 
balanced central  nerve  action. 

Keflex  Cough. 

In  post-nasal  catarrh  we  frequently  have  a  profuse  discharge  which, 
by  irritating  the  pharynx,  causes  a  cough.  This  cough  frequently  resembles 
that  of  an  acute  bronchitis.  The  examination  of  the  lungs  in  such  cases 
is  usually  negative.  It  is  tlicrefore  advisable  to  examine  the  nose  and 
throat  in  every  case  of  cough. 


CHAPTER  II. 
DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

The  Lungs. ^ 

The  lungs  in  children  occu})y  the  same  position  as  in  adult  life.  The 
trachea  of  the  young  child  is  larger  in  comparison  than  in  the  adult;  so 
also  the  bronchi  are  larger  than  in  the  adult.  They  occupy  more  space  and 
are  more  numerous  than  in  the  adult,  but  the  air-cells  are  much  smaller. 
I  have  described  in  detail  the  method  of  examination  of  the  thorax  in  the 
article  on  "The  RespiTation  in  the  New-born  Baby." 

The  Diaphragm. 

The  diaphragm  occupies  a  higher  position  in  children  than  in  adults. 
Dwight  studied  a  series  of  frozen  sections  and  found  the  diaphragm  in  the 
ijifant  corresponding  to  the  eighth  and  ninth  dorsal  vertebrae. 

Points  to  be  Noted  in  the  Diagnosis  of  Diseases  of  the  Lungs. 

auscultation. 

Acute  calarrhal  hroiichiiis:  Sibilant  and  sonorous  rales.  Large  and 
small  bubbling  rales. 

Capillary  hronchitis:    Sibilant,  subcrepitant  rales. 

Asthma:    Sibilant,  wheezing,  sonorous  breathing. 

EiiipliyseiHa:  Respirations  (liiuinished,  absent,  or  prolonged.  Low- 
pitched  e\])iration. 

(Edema:    Bilateral,  subcrepitant  rales. 

Pneamonia:  (1)  Crepitant  rales;  (2)  bronchial  breathing  and  bron- 
chophony; (3)  broncho-vesicular  breathing,  crepitant,  subcrepitant,  and 
bubbling  rales. 

Pleurisy:  Friction  sound  with  each  respiratory  act,  best  heard  with 
inspiration.  If  the  child  controls  th(»  movements  of  the  lung  and  keeps 
the  pleural  surfaces  apart,  then  no  friction  sound  is  heard. 

Subacute  pleurisy:  Friction,  absence  of  vesicular  murmur,  and  vocal 
resonance. 

Fluid  and  air  in  pleural  sac:  Respiratory  murmur  absent,  amphoric 
breathing  above,  all  sound  absent  below,  splashing  rales. 


'  Acute  tuberculosis,  tubercular  piieuiiionia,  and  lobar  pneumonia  are  described 
in  Part  VII,  in  the  "Acute  Infectious  Diseases." 

(450) 


VOCAL  RESONAKCE.  451 

Tuberculosis:  Long,  high-pitched  expiration,  breathing  feeble,  vocal 
resonance  increased,  adventitious  rales,  later  bronchial  breathing,  bron- 
chophony. 

Tuberculosis,  second  stage:  Cavernous  breathing,  amphoric  breathing, 
iiurgles,  metallic  echo. 

PERCUSSION  RESONANCE. 

Vesicular:   Uncomplicated  lung. 

Dullness:   Lung  with  increased  proportion  of  solids. 

Flo  I II  ess:    Solids,  fluids. 

Tympanitic:    Large  body  of  air. 

V esiculo-tympanitic :    Lung  witli  increased  proportion  of  air. 

Amphoric:    Empty  cavity  with  tense  walls. 

Cracked- pot:    Cavity  with  flaccid  walls. 

RHYTHM, 

Normal  rhythm:  Eegular  succession  of  the  respiratory  acts. 
Interrupted  rhythm:    Slight  deposit  in  lung. 
Divided  rhythm:    Want  of  elasticity  in  lung. 
Prolonged  expiration:    Want  of  elasticity  in   lung. 

BREATHING. 

Vesicular:    Uncomplicated  lung. 

Bronchial:    Consolidated  Kmg;    compressed  lung. 

Broncho-vesicular :    Moderate  consolidation,  moderate  compression. 

Cavernous:    Flaccid  cavity-walls. 

Amphoric:    Tense  cavity-walls. 

Exaggerated:    Vicarious  respiration. 

Diminished:    Plastic  exudation,  want  of  elasticity. 

Absent:   Fluid,  air. 

VOCAL   RESONANCE. 

Normal:    Voice  through  normal  chest. 
Bronchophony:    Voice  tlirough  consolidation. 
Amphoric:  Voice  in  a  cavity. 
JEgophony:    Voice  in  compressed  Inng. 
Pectoriloquy:    Articulate  voice  in  cavity;    in  consolidation. 
Whispering  pectoriloquy:    Whispered  articulation  in  cavity;    in  con- 
solidation. 

Cavernous  irhisper:     Ill-dofnicd   nrticidiitinn    in   cavity. 


452  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 


BRONCHms  (Bronchial  Catarrh,  Acute  Bronchitis). 

Bronchitis,  commonly  known  as  bronchial  catarrh,  is  one  of  the  most 
frequent  diseases  of  infancy  and  childhood.  It  frequently  follows  nasal 
catarrh,  pharyngeal  catarrh,  or  catarrh  extending  from  the  trachea. 

Etiology. — There  are  certain  predisposing  factors  which  favor  the 
development  of  this  disease.  Children  with  deficient  nutrition,  suffering 
with  anaemia,  and  those  with  a  weakened  framework  having  rickets,  are 
more  susceptible  to  this  disease.  Children  affected  with  catarrh  of  the 
upper  air  passages  frequently  invite  an  extension  of  this  inflammatory 
process. 

Bacteriology. — The  pathogenic  bacteria  found  in  the  bronchi  are  sta- 
phylococci, streptococci,  colon  bacilli,  and  diphtheria  bacilli.  The  bacteria 
most  frequently  seen  are  the  diplococci  of  pneumonia  and  streptococci;  in 
addition  to  these  the  bacillus  of  influenza  frequently  gives  rise  to  bron- 
chitis. Other  germs  found  were  bacillus  pyocyaneus  and  encapsulated  ba- 
cilli. Kitchie^  states  that  the  above  micro-organisms  were  rarely  found 
alone,  but  always  associated.  He  does  not  believe  that  a  definite  germ  is  the 
causative  agent.  These  same  micro-organisms  under  different  conditions 
frequently  enter  the  alveoli  and  produce  pneumonia. 

Pathology. — The  anatomical  changes  noted  in  bronchitis  are  the  same, 
irrespective  of  the  cause.  The  disease  may  be  limited  to  the  large  bronchial 
tubes  or  may  extend  into  the  finest  ramifications.  This  tendency  to  extend 
into  the  capillaries  is  greater  in  children  and  still  more  so  in  infants.  The 
accumulation  of  the  catarrhal  products  in  the  smaller  tubes  adds  a  gravity 
of  its  own  to  the  situation.  It  is  well  to  emphasize  this  peculiar  tendency 
of  the  trouble  in  those  of  tender  age.^ 

On  making  a  cross-section  of  the  lung  a  muco-purulent  discharge  oozes 
from  the  bronchi.  The  same  thick  purulent  matter  can  be  forced  out  of 
the  smaller  tubes  when  compressing  the  lung  between  the  fingers.  The 
microscopic  examination  shows  intense  congestion  of  the  superficial  blood- 
vessels. Frequently  there  is  a  serous  infiltration  of  the  bronchial  mucous 
membrane. 

When  the  infection  extends  into  the  smallest  bronchi  it  is  called  '^capil- 
lary  bronchitis."  Williams  calls  it  ^^suffocative,"  owing  to  the  severe  symp- 
toms which  develop. 

Capillary  bronchitis  is  always  accompanied  by  some  alveolar  catarrh 
and  frequently  passes  on  to  a  distinct  broncho-pneumonia.  Infectious  secre- 
tions in  the  larger  bronchi  are  sometimes  sucked  into  the  smaller  bronchi 


'  Journal  of  Pathology  and  Bacteriology,  1900,  vii,  1-21. 

*  Christopher :     Article  on  "Bronchitis,"  "American  Text-Book  on  Diseases  of 
Children." 


BRONCHITIS.  453 

and  frequently  cause  an  inflammation  of  the  lobule.  A  plug  of  mucus 
frequently  acts  as  a  valve  in  a  bronchus,  permitting  some  air  to  escape 
during  expiration  and  preventing  the  entrance  of  air  during  inspiration. 

When  all  the  air  is  expelled  the  lobule  may  collapse.  This  condition 
is  known  as  atelectasis  pulmonum.  This  condition  is  favored  when  the 
thorough  expansion  of  the  air  tubes  is  interfered  with.  It  is  also  favored 
by  congestion,  thickening  of  the  mucous  membrane,  and  the  gummy  secre- 
tions produced  by  bronchitis. 

It  moreover  accompanies  those  cases  in  which  the  position  is  not  fre- 
quently changed.  It  is  seen  in  rachitic  deformities  of  the  thorax.  The 
most  frequent  place  for  this  condition  is  at  the  border  of  the  lungs.  The 
collapsed  area  is  of  a  dark  red  or  purple  color  and  shows  a  unifom  red 
surface  on  section.  It  sinks  in  water,  but  can  be  insufflated  unless  inflam- 
mation has  already  begun  (Williams). 

Eachford  has  shown  that  disease  of  the  lymphatic  system  is  a  factor 
in  producing  malnutrition  in  children.  In  children  having  the  latter  con- 
dition we  must  not  be  surprised  if  we  have  a  persistent  bronchial  catarrh 
baffling  the  ordinary  method  of  treatment. 

Symptoms  and  Diagnosis. — The  symptoms  vary  with  the  severity  of  tlie 
disease,  in  mild  cases  the  temperature  rises  to  a!)out  101°  F.  at  night;  in 
severer  cases  the  temperature  will  reach  102°  F.  and  even  103°  F.  Tlie 
respirations  are  quickened  and  labored  and  the  pulse  is  accelerated.  When 
the  temperature  is  subnormal  in  rachitic  children,  then  such  low  temperature 
should  be  looked  upon  as  a  grave  symptom.  On  auscultation  sibilant  rales 
ai"e  heard  anteriorly,  but  more  prominent  posteriorly. 

As  the  secretion  from  the  mucous  membrane  begins  the  sibili  gives 
place  to  loose  mucous  rales.  Graves's  point  is  worth  noting,  that  "the 
more  numerous  the  sounds  heard  at  any  one  point  to  which  the  stethoscope 
is  applied  the  smaller  the  bronchi  involved." 

Much  stress  should  not  be  laid  on  the  sputum  or  the  character  of  the 
expectoration.  Children  under  5  years  rarely  or  never  expectorate.  The 
pulmonic  resonance  is  usually  normal.  If  the  attack  is  a  mild  one,  as  the 
above-named  symptoms  would  seem  to  indicate,  then  the  symptoms  will 
subside  under  palliative  treatment.  The  greatest  attention  should  be  be- 
stowed on  the  pulse. 

A  pulse-rate  between  120  to  130  in  a  young  child  should  be  looked 
upon  favorably.  If  the  pulse  is  suddenly  accelerated  and  reaches  140 
to  160  and  the  respirations  are  increased  to  60  or  80  per  minute,  then  a 
broncho-pneumonia  should  be  suspected.  Bear  in  mind  that  the  normal 
ratio  of  respiration  to  pulse  is  about  1  to  1^;  when  this  is  disturbed  so  that 
the  ratio  is  1  to  2,  or  even  1  to  3,  we  should  suspect  pneumonia. 

Prognosis. — This  varies  according  to  the  severity  of  the  symptoms  and 
the  condition  of  the  infant  before  it  was  taken  sick.     Children  having  a 


454  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA.  ' 

cachectic  condition  or  those  having  syphilis  will  certainly  have  a  severer 
type  of  infection  than  children  not  so  affected.  In  subnormal  conditions- 
bronchitis  will  frequently  leave  some  traces,  so  that  a  "chronic  bronchitis" 
is  established. 

Treatment. — Hygienic  Treatment:  A  child  with  bronchitis  must  be 
put  to  bed  in  a  room  having  a  temperature  of  68°  to  72°  F.  The  air  should 
be  kept  free  from  dust.  The  room  must  be  properly  ventilated.  The  pa- 
tient should  be  given  as  much  sunshine  as  possible.  Dark,  ill-ventilated 
rooms  will  aggravate  this  condition.  The  body  should  be  warmly  clad — 
not  too  warm.  Flannels  should  be  worn  next  to  the  skin.  A  lukewarm 
sponge  bath  followed  by  friction  witli  a  course  towel  will  stimulate  the 
oirculiition  and  is  very  grateful  to  the  child.  Tf  the  child  bns  a  high  tein- 
})erature  then  a  mustard  foot  l)ath  should  be  ordered. 

Dietetic  Treatment. — If  the  child  takes  a  large  amount  of  nourish- 
ment and  assimilates  the  same,  then  the  chances  of  restoring  health  are 
excellent.  To  rely  on  drugs  and  exclude  food  is  to  discard  the  most  impor- 
tant part  of.  the  treatment.  When  the  child  refuses  food  by  mouth,  then 
rectal  feeding  should  be  resorted  to,  so  that  the  body  is  sufficiently  nourished. 
It  is  a  good  plan  to  predigest  milk  for  feeble  infants,  hence  peptonized 
milk  or  whey  and  soups  and  broths  should  not  be  forgotten.  The  yolk  of 
an  egg  beaten  up  with  sherry  wine  for  a  child  several  years  old  will  be 
found  a  convenient  method  for  giving  nourishment  with  stimulation.  Water 
is  very  important  in  the  treatment  of  this  disease,  especially  so  when  there 
is  a  large  amount  of  expectoration. 

Medicinal  Treatment. — If  the  temperature  is  over  102°  F.,  l-drop 
doses  of  tincture  of  aconite,  given  every  two  hours,  will  be  useful  to  reduce 
the  fever.  All  children  who  cougli  swallow  their  mucus,  hence  a  laxative 
or  an  emetic  will  be  very  serviceable.  A  teaspoonful  of  castor-oil,  repeated 
in  six  hours,  is  very  valuable.  As  an  emetic  a  teaspoonful  of  syrup  of 
ipecac,  repeated  in  fifteen  or  twenty  minutes  if  necessary,  can  be  tried. 
When  rapid  emesis  is  desired,  1  grain  of  sulphate  of  copper  dissolved  in  a 
teaspoonful  of  water  will  be  very  effective.  This  dose  should  not  be  re- 
peated more  than  once  in  two  or  three  hours.  Apomorphin  in  doses  of 
Vioo  grain,  hypodermically,  is  a  very  effective  emetic.  This  is  indicated 
when  the  child  refuses  to  take  medicine. 

When  the  secretion  is  very  viscid  then  steam  inhalations  will  be  very 
serviceable.  The  steam  atomizer  will  be  found  very  valuable  in  young 
children  who  cannot  be  held  over  moist  vapor.  Steam  impregnated  with 
beechwood  creosote  will  be  found  not  only  a  valuable  means  of  loosening 
adherent  mucus,  but  it  has  a  decided  therapeutic  effect.  It  is  a  powerful 
antiseptic. 

Restorative  Treatment. — Restorative  treatment,  such  as  using  an 
emulsion  of  codliver-oil  or  a  malt  extract,  with  or  without  iron,  should  not 
be  omitted. 


BRONCHIAL  ASTHMA.  455 

Bronchial  Asthma. 

This  is  frequently  called  spasmodic  asthma,  owing  to  the  spasmodic 
or  paroxysmal  dyspnoea  associated  with  wheezing  respiration.  A  pecul- 
iarity of  this  condition  is  that  children  appear  to  be  perfectly  well  during 
the  intervals. 

Etiology. — Children  having  neurotic  tendencies  or  those  children  of 
gouty  families  seem  to  be  predisposed  to  this  affection.  Most  writers  on 
this  subject  believe  that  this  condition  is  a  vasomotor  neurosis  resulting  from 
disturbed  innervation  of  the  pneumo-gastric  or  its  ramifications,  or  the 
vasomotor  nerves,  causing  a  spasm  of  the  muscles  of  the  air  passages.  Hay 
fever  is  an  affection  which  closely  resembles  bronchial  asthma  and  alter- 
nates with  it. 

Exciting  causes  are  many;  for  example,  enlarged  bronchial  glands, 
enlarged  tonsils,  adenoids,  elongated  uvula,  and  hypertrophied  turbinates. 
The  inhalation  of  irritants,  such  as  dust,  may  irritate  and  provoke  a  spasm. 
jSTot  infrequently  we  find  eczema  existing  at  the  same  time  or  alternating 
with  attacks  of  asthma. 

Gastro-intestinal  disturbances  are  among  the  most  frequent  causes  of 
asthmatic  attacks. 

Pathology. — This  is  not  known.  Talma  says:  "The  attacks  are  due 
to  a  spasm  of  the  larynx,  rarely  to  a  spasm  of  the  constrictors  of  the  glottis, 
and  that  it  is  partly  under  voluntary  control."  Various  theories  are  offered. 
One,  that  the  attack  is  due  to  a  swelling  of  the  bronchial  mucous  mem- 
brane or  to  a  catarrh  of  the  bronchioles,  or  possibly  to  a  spasm  of  the 
bronchial  muscles. 

Symptoms. — Without  warning,  a  spasm  or  shortening  of  breath  comes 
on,  most  frequently  at  night.  There  is  usually  such  oppression  and  dis- 
tressed breathing  that  the  child  must  sit  up.  Frequently  the  distress  is  so 
great  that  the  child  will  grasp  any  object  within  reach.  The  shoulders  are 
elevated  and  the  head  thrown  back  so  that  the  accessory  muscles  of  respira- 
tion are  brought  into  play.  The  face  assumes  an  anxious  expression,  and 
later  becomes  cyanotic.  The  e3'es  are  prominent  and  the  alas  nasi  widely 
dilated.  A  cold,  clammy  perspiration  is  usually  present.  The  respiration 
is  loud  and  wheezing.  The  respirations  arc  rarely  increased  in  number. 
The  inspiration  is  jerky,  the  expiration  prolonged  and  laborious.  There 
is  very  little  or  no  thoracic  expansion.  The  pulse  is  small  and  rapid.  There 
is  no  fever,  but  we  frequently  have  a  subnorinal  temperature  when  the 
attack  is  prolonged.  The  extremities  are  frequently  cold.  After  the  attack 
there  is  exhaustion  followed  by  sleep.  An  attack  may  last  several  hours, 
sometimes  days.  Percussion  of  the  chest  during  the  paroxysm  shows  hyper- 
resonance.  There  may  be  either  diminution  or  prolongation  of  the  vesicular 
murmur.  The  whole  chest  has  sibilant  and  sonorous  rales  and  wheezing 
sounds. 


456  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  TLEURA. 

The  diagnosis  is  easy;  we  must  exclude  spasm  of  the  glottis,  croup, 
tracheal  stenosis,  and  neoplasm  in  the  larynx.  The  absence  of  fever  will 
easily  differentiate  this  condition  from  inflammatory  respiratory  diseases. 

The  prog-nosis  is  usually  good,  especially  so  at  the  time  of  puberty. 
After  an  attack  a  careful  examination  of  the  lungs,  the  kidneys,  the  nose, 
and  the  throat  should  be  made,  and  the  exciting  cause,  if  possible,  should 
be  noted. 

Treatment. — During  the  paroxysm  stramonium  leaves  can  be  ignited 
with  some  alcohol  and  the  fumes  inhaled.  Inhalation  of  the  fumea  of 
saltpeter  paper  is  very  good.  The  inhalation  of  chloroform  offers  very 
quick  relief,  so  does  nitrite  of  amyl  or  ethyl  chloride.  Opium  in  the  form 
of  Dover's  powder  or  small  doses  of  morphine  or  codeine  are  the  best 
remedies.  Chloral  hydrate  with  or  without  bromide  of  potassium  is  very 
valuable.  Belladonna  is  also  useful.  During  the  interval  iodide  of  sodium 
in  full  doses  may  be  given.  A  child  suffering  with  asthma  should  be  put 
to  bed  in  a  quiet  room  with  plenty  of  fresh  air.  A  dose  of  calomel  or  citrate 
of  magnesia,  or  5  or  10-grain  doses  of  phosphate  of  sodium,  should  be 
given  to  cleanse  the  stomach  and  bowels,  Eelief  is  frequently  afforded  by 
giving  a  very  high  colon  flushing  and  washing  away  as  much  faeces  as  pos- 
sible. The  stomach  should  be  carefully  guarded,  and  liquid,  concentrated 
food  rather  than  bulky  food,  should  be  given.  In  other  words  distention 
of  the  stomach  with  pressure  on  the  diaphragm  will  frequently  cause  a 
severe  attack.  The  kidneys  should  be  kept  active  and  stimulated  by  giving 
10  or  15-drop  doses  of  sweet  spirits  of  niter  occasionally.    * 

Broxcho-pneumonia  (Catarrhal  Pneumonia  or 
Lobular  Pneumonia). 

This  disease  derives  its  name  from  the  fact  that  it  usually  exists  as 
an  inflammatory  condition  affecting  small  areas  of  the  alveoli  of  the  lung. 
Contrary  to  lobar  pneumonia,  this  catarrhal  form  does  not  terminate  by 
a  distinct  crisis.  This  disease  is  usually  a  sequela  to  or  a  complication  of 
whooping-cough,  measles,  diphtheria,  or  typhoid  fever.  It  is  this  form 
which  is  most  dreaded  in  diphtheria  and  which  rarely  ends  favorably. 
It  does  not  occur  in  distinct  cycles  nor  does  it  run  a  distinct  course.  One 
child  may  suffer  with  a  broncho-pneumonia  extendiog  over  ten  days  or 
two  weeks.  Another  child  with  the  same  form  and  severity  of  the  dis- 
ease may  suffer  from  eight  to  ten  weeks.  Thus  this  disease  may  be  con- 
sidered to  be  of  a  distinct  wandering  type.  This  disease  does  not  depend 
on  seasonal  changes,  although  the  greatest  number  of  cases  are  met  with 
in  the  spring  and  fall.  Infants  and  nurslings  as  well  as  older  children  seem 
to  be  equally  affected. 

Etiology. — By  far  the  greatest  number  of  catarrhal  pneumonias  may 
be  found  in  those  children  offering  the  least  resistance.     Such  cases  are 


bronlho-pneumonia. 


457 


usually  found  in  scrofulous,  tuberculous,  rachitic,  and  syphilitic  children. 
When  children  have  previously  suffered  from  infectious  such  as  diphtheria, 
scarlet  fever,  measles,  or  typhoid  fever,  they  are  peculiarly  predisposed  to 
this  secondary  infection.  It  is  for  this  latter  reason  that  this  disease  is  so 
fatal.  In  a  series  of  fatal  cases  accompanying  the  various  types  of  diph- 
theria seen  by  me  at  the  Willard  Parker  Hospital,  the  large  bulk  suc- 
cumbed to  this  complication.  This  is  due  in  a  great  measure  to  the 
devitalized  condition  of  the  body  after  a  toxaemic  infection,  such  as  is 
found  in  diphtheria.  Whether  or  not  this  disease  is  contagious  has  not 
been  definitely  settled. 

Bacteriology. — We  know  that  various  forms  of  germs,  such  as  the 
staphylococcus,  streptococcus,  the  diplococcus  pneumonia  (Priedlander), 
the  diplococcus  (Fraenkel),  and  bacterium  eoli,  are  among  the  specific 
micro-organisms  which  have  been  found  intimately  associated  with  this 
disease. 


Fig.  138. — Diplococcus  Pneumoniae  (Pneumococcus)  :  (a)  single  diplo- 
cocci;  (6)  the  same  in  chains  (Wolf's  double  stain).  Leitz  ocular  I,  oil 
immersion  Vi2-      (Lenhartz-Brooks.) 

Pathological  Anatomy. — The  tracheal  and  bronchial  mucous  mem- 
brane is  intensely  congested,  and  the  lumen  of  the  smaller  bronchi  filled 
with  thick  muco-pus,  which  adheres  to  the  surfaces  and  is  as  tenacious  as 
a  pseudo-membrane.  The  lung  at  the  seat  of  infection  shows  dark  brown 
or  brownish-red,  infiltrated  areas,  sometimes  of  a  bluish-red  color.  The 
surface  of  the  pleura  contains  large  or  small  ha^morrhagic  areas.  They 
resemble  a  sort  of  hepatization,  brownish,  grayish,  or  yellowish-gray  in 
color,  and  in  some  areas  have  purulent  infiltrations.  Sometimes  the  inter- 
stitial tissue  is  associated  in  this  condition  with  a  tendency  toward  cica- 
tricial formation.  Sometimes  the  alveoli  have  an  emphysematous  disten- 
tion.    The  whole  process  seems  to  bo  a  bronchiolitis  associnted  with  cir- 


458  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 


Fig.  139. — Purulent  (Suppurative)  Bronchitis,  Peribronchitis  and  Peri- 
bronchial Broneho-pncunionia  in  a  Child  Fifteen  Months  Old.  («)  Puru- 
lent; (6)  mucoid  bronchial  contents;  (c,  c')  bronchial  epithelium  inliltrated 
with  round  cells  and  partly  desquamated  (cM  ;  [d)  bronchial  wall  contain- 
ing strongly  congested  blood-vessels  and  infiltrated  with  cells;  (c)  cellular 
infiltrated  peribronchial  and  periarterial  connective  tissue;  (/)  septum  be- 
tween tiie  lung  alveoli,  partly  infiltrated  with  cells;  {g)  fibrinous  exudate 
in  the  alveoli;  (h)  alveoli  filled  with  richly  cellular,  (i)  with  poorly  cellular 
exudate;  (A)  transverse  section  of  pulmonary  arteries;  (/)  strongly  con- 
gested bronchial,  peribronchial  and  intra-acinous  vessels.     X  45.      (Z'iegler.) 

cumscribed  atelectasis  of  the  lung,  from  which  hyperaemia  and  infiltrations 
of  tissue  result. 

Symptoms. — The  symptoms  are  those  of  a  bronchial  catarrh  and  a 
bronchitis.  Associated  with  this  there  is  the  usual  fever,  restlessness,  and 
an  increased  frequency  of  respiration;  there  is  also  dyspnoea.  There  is  a 
distinct  cyanosis  affecting  not  only  the  face  and  lips,  but  frequently  the 
nails.  There  is  an  anxious  expression  to  the  countenance.  The  alse  nasi 
participate  in  the  respiration.  The  whole  respiration  seems  to  be  super- 
ficial and  brings  every  muscle  into  action.  That  there  is  an  obstruction 
can  easily  be  seen  by  an  observation  of  the  jugulum,  by  noticing  the  inter- 
costal space  and  also  the  epigastrium,  which  sinks  at  each  inspiration.  The 
frequency  of  respiration  will  sometimes  be  increased  to  70  or  80  per  min- 
ute, and  it  is  very  jerky  in  character.  The  pulse-rate  will  suddenly  rise  to 
140  or  160,  and  frequently  in  some  cases  to  200  per  minute.  The  tem- 
perature may  be  as  low  as  100°  F.  and  gradually  rise  one  degree  or  more 
each  day.    It  may  reach  104°  or  105°  F.  in  the  evening.    The  temperature 


BROXCHO-rXEUMONLV 


459 


usually  show?  a  morning  remission  of  at  least  one  or  two  and  sometimes 
throe  degrees. 

Pictorial  illustrations  of  broncho-pneumonia  complicating  measles  and 
dij)htheria  will  be  found  in  their  rcsp(?ctive  chapters. 


WILLARD    PARKER    HOSPITAL 


X  Reintubate  1. 

Fig'.  140.- -Louis  B.  Age  3  years.  This  very  instructive  case  illus- 
trates the  tolerance  of  the  larynx  for  the  intubation  tube.  In  all  twenty 
intubations  were  performed.  The  chart  illustrates  the  tube  coughed  up  four 
times  in  one  day,  thus  re(iuiring  four  distinct  intubations  in  twenty-four 
hours.  In  spite  of  the  fact  tliat  the  case  was  septic  from  the  beginning,  and 
that  the  child  had  a  broncho-pneumonia,  the  case  recovered.  In  order  to 
retain  the  tube  and  prevent  its  being  coughed  up,  the  caliber  was  gradually 
increased  from  a  number  three  until  an  eleven  to  twelve  tube  was  used. 
(Original.) 

Physical  Examination. — The  physical  examination  of  the  thorax  shows 
moist  rales,  sibilant  or  sonorous  rales,  or  coarse  mucous  rales,  at  times  dis- 
tinct bronchial  breathing  accompanied  by  a  metallic  sound.  Percussion 
will  usually  show  dullness  over  small  areas.  "While  this  may  be  due  to  the 
localized  area  of  consolidation,  it  is  quite  possible  that  the  dullness  may 
also  be  attributed  to  enlarged  bronchial  glands  in  this  region.  AVhen  the 
disease  terminates  favorably  the  temperature  falls,  the  pulse  assumes  a 
more  regular  character,  the  heart  sounds,  which  formerly  were  feeble,  ap- 
pear louder,  stronger,  and  rhythmic.  The  cough  will  be  more  frequent, 
the  respiration  less  frequent  and  not  so  superficial.  Children  who  formerly 
were  apathetic  now  appear  to  notice  everything,  and  appear  very  sensitive 


460  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

on  hoino;  haiidlcd,  and  especially  so  durino;  an  examination.  The  physical 
signs  of  a  dilt'used  broncliitis  and  the  diifused  areas  of  moist  rales  associated 
with  the  localized  areas  of  bronchial  breathing  disappear.  The  bronchial 
breathing  which  existed  before  now  becomes  vesicular  in  character.  The 
pulse,  which  formerly  Avas  greatly  accelerated,  and  the  respiration,  which  was 
very  frequent,  now  both  return  to  their  nonnal  state.  The  whole  character 
of  this  affection  has  no  specific  rule,  but  drags  along  without  a  distinct  ter- 
mination, differing  from  that  condition  so  well  knowoi  and  described  as 
croupous  pneumonia.  It  is  not  rare  to  note  an  apparent  cessation  of  the 
inflammatory  condition  in  the  pulse,  respiration,  and  temperature,  and  to 
find  that  new  inflammation  has  begun  with  more  active  symptoms  than  has 
been  just  passed  through. 

We  can  therefore  see  that  a  l)ronelio-pncumonia  frequently  is  a  con- 
tinuance of  an  inflammation  which  spreads  from  portion  to  portion  and 
from  lobe  to  lobe,  and  thus  devitalizes  the  system.  The  symptoms  affecting 
the  gastro-intestinal  tract  and  those  of  the  genito-urinary  organs  are  the 
same  as  found  in  croupous  pneumonia. 

The  differential  diagnosis  hctwcen  catarrhal  and  fibrous  pneumonia  can 
easily  be  made  by  a  comparison  of  the  course  which  these  diseases  run. 
Catarrhal  pneumonia  commences  with  symptoms  of  a  bronchial  catarrh  or 
a  bronchitis.  These  same  symptoms  remain  during  the  course  of  the  disease. 
The  symptoms  do  not  have  those  of  an  acute  character  which  characterize 
croupous  pneumonia,  but  rather  assume  a  chronic  appearance.  The  great 
danger  consists  in  the.  development  of  pus  infiltration  in  the  lungs,  and 
it  is  only  by  the  rapid  emaciation  that  symptoms  of  miliary  tuherculos-is 
can  be  suspected. 

We  can  differentiate  catarrhal  pneumonia  from  atalectasis  by  the  total 
absence  of  fever  in  atalectic  conditions. 

Prognosis  and  Course. — The  prognosis  depends  on  the  origin  of  this 
disease.  If,  for  example,  broncho-jineumonia  is  a  sequela  to  measles,  diph- 
theria, whooping-cough,  scarlet  fever,  or  typhoid,  and  the  child  has  passed 
through  a  severe  infection  in  which  the  corpuscular  elements  of  the  blood 
have  greatly  suffered,  then  the  prognosis  is  grave.  If,  on  the  other  hand, 
this  disease  commences  as  a  primary  affection  and  the  child  is  in  a  fairly 
well-nourished  condition,  then  the  prognosis  is  good.  The  prognosis  will 
chiefly  depend  on  the  amount  of  food  that  can  be  properly  assimilated  and 
the  care  with  which  the  case  is  nursed.  The  course  is  slow  and  tedious, 
and  may  develop  tubercular  pneumonia. 

The  hygiene  is  very  important  in  this  condition.  The  prognosis  of 
catarrhal  pneumonia  following  whooping-cough,  measles,  or  diphtheria  will 
usually  show  tliat  almost  70  per  cent,  of  cases  so  affected  are  fata^ 

Treatment. — If  the  temperature  is  high,  antipyretic  remedies,  such  as 
the  coal-tar  products,  are  not  indicated,  owing  to  their  well-known  de- 


I 


I 

1 


BRONCHO-PNEUMONIA.  461 

pressing  effect  upon  the  heart.  The  author  has  never  used  them  without 
seeing  an  ill  effect.  When  they  are  used  they  should  be  combined  with 
camphor  or  musk  to  counteract  this  well-known  depression.  The  safest 
antipyretic  measure  in  pulmonic  affections  is  undoubtedly  hydrotherapy. 
A  cold  compress  applied  over  the  thorax  and  repeated  once  every  half-hour, 
not  only  acts  as  an  antipyretic,  but  will  stimulate  the  respiratory  muscles 
and  provoke  deep  inspirations.  This  will  distend  the  smaller  portions  of 
the  alveoli  and  will  prevent  atalectasis  pulmonum.    If  there  is  very  great 


Fig.  141. — Diagram  for  Pneumonia  Jacket  Opened  at  Side. 


Fig.    142. — Diagram   for   Pneumonia   Jacket  Opened  in   Front.      (Original.) 

dyspnoea  owing  to  the  presence  of  viscid  secretions,  then  an  emetic  is  indi- 
cated. One  of  our  best  emetics  is  sulphate  of  copper  in  1-grain  doses,  re- 
peated m  an  hour  if  necessary.  Another  emetic  and  one  which  is  less 
irritating  than  the  above  is  syr.  scilla3  comp.  in  1/2  to  1  teaspoonful  doses, 
repeated  every  half-hour  until  the  desired  effect  is  produced.  Syrup  of 
ipecac  in  doses  of  one  teaspoonful,  repeated  every  fifteen  to  twenty  minutes, 
is  also  serviceable.  "When  a  cliild  has  extreme  dyspnoea  and  it  is  not  wise  to 
administer  an  emetic  by  mouth,  then  a  hypodermic  injection  of  V^^  grain 
of  apomorphia  dissolved  in  five  or  ten  minims  of  sterile  water  injected 
deeply  into  the  subcutaneous  cellular  tissue,  will  usually  provoke  emesis. 
If  this  dose  is  not  effectual  in  fifteen  or  twentv  minutes,   then   another 


462  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

dose  of  apomorphia  may  be  given.  Tartar  emetic  in  doses  of  */io  grain, 
in  sweetened  water,  may  be  given  every  hour  until  vomiting  is  produced.  It 
is  better  not  to  change  from  one  drug  to  another  unless  several  doses  have 
proven  ineffectual. 

Flaxseed  poultices  are  sometimes  recommended  when  the  secretions 
are  very  viscid.  These  have  frequently  proven  efficacious  in  the  hands 
of  the  author.  In  urgent  dyspnoea  great  relief  can  be  afforded  by  the  appli- 
cation of  dry  cups  over  the  affected  areas  of  the  lungs. 

A  ptieumonia  jaclxt  consisting  of  cheese  cloth,  which  is  worn  next 
to  the  skin,  then  a  layer  of  cotton  wool,  and  the  whole  covered  with  oiled 
silk  or  oiled  muslin,  will  serve  to  prevent  chilling  of  the  surface.  Figs. 
141  and  142  show  diagrams  of  these  jackets. 

Internal  diffusible  stimulations,  such  as  ^/j-grain  doses  of  carbonate 
of  ammonia,  repeated  every  hour,  are  serviceable.  Liq.  ammon.  anisati,  in 
doses  of  from  3  to  10  drops,  repeated  every  hour,  is  one  of  our  best  dif- 
fusible stimulants.  If  symptoms  of  collapse  appear  then  active  alcoholic 
stimulation  must  be  resorted  to,  such,  for  example,  as  champagne,  brandy, 
whisky,  or  wine  ad  libitum.  In  addition  thereto,  a  sinapism  over  the  front 
and  back  of  the  chest  and  mustard  foot  baths  may  be  required.  Hypo- 
dermic medication  will  frequently  be  found  necessary,  especially  if  the 
heart's  action  is  feeble.  One  two-hundredth  of  a  grain  of  nitro-glycerine 
injected  hypodermically  or  caffeine  citrate  will  sometimes  work  well. 
Strychnine  sulphate  in  doses  of  V200  grain,  gradually  increased,  repeated 
every  three  or  four  hours  or  oftener,  will  stimulate  the  heart's  action.  An 
excellent  heart  stimulant  is  to  give  1  drop  of  tincture  of  musk  every  hour. 

If  the  cough  is  very  troublesome,  especially  at  night,  and  the  child  is 
in  a  fair  physical  condition,  then  codeine  in  doses  of  ^/oq  to  ^/^o  grain  for 
a  child  1  year  old,  repeated  every  two  or  three  hours,  will  relieve.  Dionin  ia 
a  remedy  that  has  been  used  by  the  writer  with  considerable  success  in  the 
treatment  of  various  forms  of  cough  in  doses  of  ^/^o  grain,  repeated  every 
three  or  four  hours,  for  a  child  1  year  old. 

Stimulating  expectorants  such  as  syrup  of  senega,  in  doses  of  from  10 
to  15  minims,  may  be  advantageous.  The  vital  point  to  remember  is  to 
support  the  system  with  nourishment.  If  the  child  will  not  take  food 
per  mouth,  then  rectal  feeding  consisting  of  nutrient  enemas  is   demanded. 

Water  should  be  given  freely  during  the  course  of  a  broncho-pneumonia 
to  stimulate  the  action  of  the  kidneys. 

Pulmonary  Gangrene. 

This  condition,  fortunately,  is  very  rare. 

Diagnosis. — This  is  made  by  the  characteristic  foul  odor  of  the  breath 
and  the  expectorated  gangrenous  material.  I  have  seen  a  case  of  this  kind 
during  my  summer  service  at  the  Willard  Parker  Hospital  in  a  child  that 


PLEURISY. 


463 


suffered  with  laryngeal  diphtheria  complicated  by  broncho-pneumonia.  The 
septic  condition  dragged  on  for  weeks.  There  was  a  very  putrid  odor  to 
the  breath.  The  child  finally  died  of  sepsis.  As  a  rule  the  diagnosis  can 
only  be  made  post-mortem. 

Treatment. — Eestorative  treatment,  consisting  of  light  nutritious  diet, 
should  be  given  and  stimulants  liberally  used.  Steam  inhalations  impreg- 
nated with  beechwood  creosote  will  modify  the  odor.  Creosote  carbonate 
can  be  given  with  the  food  in  5  to  10-minim  doses,  several  times  a  day. 

Pleurisy. 

An  inflammation  of  the  pleura  is  by  no  means  rare  in  children.  It 
is  found  very  frequently  post-mortem,  although  no  evidence  of  the  same 
existed  intra  vitam.    It  may  be  a  primary  condition. 

There  are  two  distinct  forms  of  pleurisy  usually  seen:  1.  Pleuritis 
sicca  (dry  pleurisy).  2.  Pleuritis  exudativa.  The  latter  form  can  again 
be  divided  into  (a)  serous,  (b)  sero-purulent,  (c)  purulent,  (d)  hemor- 
rhagic. 

The  last  mentioned  is  a  rare  condition.  It  is  seen  in  traumatic  con- 
ditions, in  hsemophilia,  and  occasionally  when  tuberculosis  is  present. 

Dry  Pleurisy. 

This  form  of  pleurisy  usually  follows  an  exposure  to  cold,  although 
it  may  follow  as  a  secondary  inflammation  to  the  lung.  There  is  usually 
an  exudation  of  fibrin  only. 

Pathology. — The  pleura  is  swollen  and 
thickened,  and  there  is  an  exudation  of  fi- 
brin. Adhesions  frequently  result  from 
these  bands  of  fibrin  between  the  opposite 
pleural  surfaces.  The  pleura  loses  its 
natural  lustre.  When  the  process  ceases 
and  the  lymph  is  absorbed,  the  condition 
is  called  "dry  pleurisy."  The  fibrinous 
bands  between  the  pleura  costalis  and  pul- 
monalis  usually  leave  permanent  adhe- 
sions. 

Symptoms. — The  disease  is  usually 
ushered  in  with  high  fever  which  may  reach 
104°  or  105°  F.  Cough  is  usually  present. 
It  is  a  short,  hacking,  irritating  cough.  It 
is  accompanied  with  pain.  As  a  rule 
children  cry  during  each  coughing 
paroxysm.  There  is  no  expectoration 
fine    crepitant    rale    is    heard    over    the 


\:>av\o\\^\'3e.^^^ 


Fig.  143. — Fever  Curve  in  a  Case 
of  Dry  Pleurisy.     (Original.) 


A    friction 
affected 


sound    or    a 
area.       There     is 


464  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

vesicular  breathing.  The  percussion  is  rarely  abnormal.  The  tongue  is 
usually  coated.  The  bowels  are  constipated.  The  urine  is  scanty.  The 
surface  of  the  body  is  dry  and  warm.  There  is  usually  a  gradual  increasing 
dyspnoea.  The  pulse-rate  is  increased,  so  also  are  the  respirations.  The 
symptoms  resemble  those  of  a  pneumonia  and  can  rarely  be  differentiated 
without  a  careful  physical  examination.  There  is  usually  pain  on  percus- 
sion over  the  affected  area.  The  children  do  not  wish  to  be  handled,  but 
prefer  to  lie  quietly. 

The  diagnosis  depends  on  the  symptoms  above  described  We  must 
bear  in  mind  tiie  frequency  with  which  pulmonary  complications  are  asso- 
ciated. 

The  prognosis  is  usually  good,  although  adhesions  frequently  remain. 

Treatment.- -Counter-irritation,  such  as  cupping  of  the  chest,  the 
application  of  iodine  over  the  affected  area,  or  painting  with  cantharidal 
collodion,  acts  well.  Strapping  the  chest  with  broad  straps  of  adhesive 
plaster  or  the  application  of  a  very  tight-fitting  bandage,  seems  to  sup- 
port the  chest  and  relieve  the  cough.  Calomel  is  indicated  especially  if 
constipation  accompanies  this  condition.  Iodide  of  sodium  with  very  small 
doses  of  codeine  may  be  given  at  regular  intervals  to  relieve  pain.  A  full 
dose  of  codeine  or  morphine  may  be  given  at  night  if  the  cough  is  distress- 
ing or  the  pain  acute.  I  have  given  from  ^/jo  to  ^/jo  grain  of  morphine 
hypodermically  to  a  child  2  years  old  to  relieve  a  severe  cough. 

Pleurisy  with  Effusion  (Pleueitis  Exudativa). 

This  secondary  form  of  pleurisy  is  usually  a  complication  or  an  exten- 
sion of  the  infection  in  pneumonia.  It  is  frequently  met  with  in  influenza 
and  in  infectious  diseases.  I  have  frequently  seen  pleurisy  with  effusion 
in  the  scarlet  fever  wards  of  the  Eiverside  Hospital.  I  have  also  seen  pleu- 
risy complicating  tuberculosis  and  rheumatism  in  children. 

Bacteriology. — In  some  cases  the  streptococcus,  in  others  the  staphy- 
lococcus, is  present.  A  diplococcus  has  also  been  found  and  believed  by 
some  to  be  the  cause  of  pleuritis.  The  pneumococcus  has  been  found  pres- 
ent, so  that  it  is  difficult  to  state  which  pathogenic  microbe  is  the  true  cause 
of  this  condition.  Whether  this  microbe  gains  entrance  to  the  pleura  from 
the  lung  by  inhalation  or  through  the  skin,  or  whether  the  tonsil  is  the 
means  of  entrance  of  the  pathogenic  bacteria,  causing  this  disease,  has  not 
been  definitely  determined.  We  know  that  suppuration  in  other  parts  of 
the  body,  as,  for  example,  in  the  abdomen  or  in  the  spine,  can  frequently 
carry  microbic  elements  to  the  pleura  and  thus  directly  transmit  the  infec- 
tion. Pyogenic  bacteria  may  be  carried  to  the  pleura  through  the  lymph 
channels  and  by  the  circulation. 

Pathology. — This  form  of  exudative  pleurisy  is  the  one  most  frequently 
encountered.    We  rarely  find  both  sides  involved,  although  a  double  pleu- 


PLEURISY  WITH  EFFUSION. 


465 


Fig. 


144. — Fever  Curve  in  a  Case  of  Pleurisy 
with  Effusion.     (Original.) 


risy  is  by  no  means  rare.  The  pathological  condition  is  practically  the  same 
as  described  in  the  chapter  on  "Dry  Pleurisy/'  In  this  condition  we  have 
more  or  less  serous  effusion.  The  serum  may  be  clear,  it  may  be  bloody,  or 
it  may  be  turbid.  Serous  effusions  found  in  a  healthy  child  are  usually 
absorbed.  Adhesions  are  frequently  left  in  this  form  of  pleurisy. 
Symptoms. — The  fever 

may  be  high  or  low.     Fever  \:iQJ\  <iV^\^^^'b'^ 

and  general  malaise  accom- ■ — ■ — ■ — ■    ■   "  "■ — ■* 

panied  by  a  hacking  cough 
will  frequently  be  the  only 
symptoms.  I  have  fre- 
quently seen  children 
brought  to  my  clinic  with 
the  history  of  a  cough,  no 
expectoration,  anorexia,  with 
general  weakness  and  ema- 
ciation, in  whom  a  pleurisy 
with  a  large  effusion  was 
detected. 

Diagnosis. — The  diag- 
nosis in  very  young  children 
is  at  times  difficult.  It  can 
only  be  made  by  a  most  careful  physical  examination  of  the  chest. 

Physical  Signs. — Before  the  effusion  h  marked  and  during  its  absorp- 
tion friction  sounds  are  heard  over  the  inflamed  area.  After  the  effusion 
is  present  there  are  no  friction  sounds.  There  is  an  absence  of  rales,  dis- 
tant bronchial  breathing  and  flatness  on  percussion.  There  is  diminished 
breathing,  so  that  the  voice  or  the  cry  of  the  child  will  appear  very  distant. 
At  the  level  of  the  fluid  the  voice  has  a  tremulous  sound,  known  as  cegophony. 
There  is  a  bulging  of  the  intercostal  spaces.  The  breathing  is  bronchial  or 
tubular.  Not  infrequently  the  heart  is  displaced.  A  careful  inspection  of 
the  chest  will  show  that  there  is  a  loss  of  motion  on  the  affected  side  during 
respiration. 

In  some  cases  the  diagnosis  depends  on  the  result  of  an  exploratory 
puncture  with  a  clean  (aseptic)  needle  having  a  large  caliber.  One  of  the 
best  needles  for  this  purpose  is  one  similar  to  that  used  for  the  injection 
of  antitoxin.  A  puncture  should  be  made  after  washing  the  skin  with 
soap  and  water  followed  by  alcohol  or  ether.  The  needle  is  then  inserted 
about  one  inch.  Sometimes  it  is  necessary  to  make  several  exploratory 
punctures  in  order  to  find  the  liquid,  especially  so  in  the  encapsulated  form 
of  pleurisy,  where  a  small  area  is  involved.  After  withdrawing  the  liquid 
the  character  of  the  same  should  be  determined  by  examining  it  under  the 
microscope.    If  pus  corpuscles  are  found  we  should  insist  on  an  operation, 

30 


466  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

as  no  other  treatment  will  be  satisfactory.  Not  infrequently  a  serous  effu- 
sion will  be  absorbed  by  the  exploratory  puncture,  so  that  the  puncture  is  at 
times  a  very  valuable  therapeutic  adjunct. 

Treatment. — Firm  strapping  of  the  chest  with  bands  of  adhesive 
plaster  is  useful;  5  to  15-grain  doses  of  iodide  of  sodium,  according  to 
age,  may  be  administered  three  times  a  day  in  milk,  soup,  or  broth.  Fresh 
air  should  be  constantly  permitted.  If  pain  is  absent  then  gentle  but  long 
inspirations  and  expirations  (pulmonary  gymnastics)  are  worth  trying. 
By  properly  exercising  the  lungs  we  can  stimulate  nutrition  to  the  parts 
and  frequently  assist  in  the  absorption  of  an  effusion. 


Fig.  145. — Diagrammatic  Illustration  of  Heart  and  Lungs  in  a  Left-sided 
Pleuritic  Effusion,  a.  Heart,  b.  Compressed  lung,  area  of  bronchial  breath- 
ing and  crepitant  rales,    c.  Effusion.     (Original.) 

Dietetic  Treatment. — No  matter  what  form  of  treatment  is  instituted, 
nothing  will  avail  so  much  as  proper  feeding.  The  dairy  products — milk, 
eggs,  and  cheese — in  conjunction  with  cereals  and  fruits,  should  form  the 
bulk  of  the  food  ordered.    Concentrated  soups  and  broths  are  also  useful. 

Empyema  (Purulent  Pleurisy). 

Etiology. — As  a  rule  we  find  this  disease  following  pneumonia  or  pleu- 
risy. It  is  a  favorite  complication  of  the  infectious  diseases,  so  that  after 
a  pneumonia  in  an  acute  infectious  disease  we  must  not  be  surprised  to  find 
an  empyema. 


EMPYEMA.  467 

Bacteriology. — The  bacteria  most  frequently  found  are  tlie  strepto- 
coccus, the  stapliylococcus,  and  tlie  pneuniococciis.  Earely  lias  the  tubercle 
bacillus  been  found. 

Pathology. — The  surface  of  the  pleura  is  covered  with  librin  and  pus 
and  the  cavity  11  lied  with  a  purulent  exudate,  the  result  of  this  inflamma- 
tion.   The  pus  settles  to  the  bottom  of  the  pleural  sac. 

Xot  infrec[uently  both  pleura?  l)ecome  involved,  although  the  rule  is 
to  find  but  one  pleura  or  part  of  it  atfected.  When  not  treated  the  pus  may 
rupture  into  the  lung  or  burrow  externally  through  an  intercostal  space. 

Symptoms. — The  most  pronounced  symptoms  are  flatness  on  percussion 
and  diminished  respiratory  sounds.  Sometimes  they  are  totally  absent. 
There  is  also  a  loss  of  the  vocal  fremitus.  At  the  level  of  tlie  fluid  the  roice 
lias  a  tremulous  cjuality  known  as  wyophony. 

Above  the  fluid  the  breathing  is  broncho- vesicular  due  to  tiie  com- 
pressed lung.    Pleurothotonos  is  sometimes  seen. 

There  is  an  absence  of  expansion  of  the  chest  on  the  atfected  side. 
When  this  condition  exists  on  the  left  .side  it  may  displace  the  heart. 

/  rely  upon  the  examination  of  the  hlood,  in  addition  to  the  physical 
signs  given,  as  an  important  guide  in  determimng  the  presence  of  pus  in  the 
system.  See  article  and  illustration  of  "Blood  Reaction  of  Pus"  in  the 
chapter  on  "Blood." 

Diagpiosis. — If  the  fever  continues  after  a  case  of  pneumonia,  or  pain 
in  the  chest  persists  accompanied  by  dypsncea,  cough,  and  sweats,  then 
empyema  should  be  suspected. 

When  the  disease  progresses  the  temperature  frequently  returns  to 
normal  or  nearly  so.  The  child  shows  symptoms  of  general  exhaustion, 
emaciation,  and  is  extremely  anaemic.  Diarrhcea  is  a  frequent  symptom  in 
this  condition. 

The  physical  signs  above  noted  are  usually  positive.  W'hen  there  is 
any  doubt,  and  in  order  to  confirm  the  symptoms  pointing  to  an  empyeuia, 
an  exploratory  puncture  should  be  made. 

If  the  needle  is  sterile  and  sharp  and  the  surface  to  be  punctured  is 
rendered  aseptic,  then  there  is  no  risk  in  making  one  or  more  punctures  to 
aid  in  establishing  the  diagnosis. 

Choice  as  to  Where  the  Needle  is  to  he  Introduced. — My  plan  has  always 
been  to  find  l)y  percussion  the  area  having  the  greatest  dullness  or  flatness, 
•and  insert  the  needle  after  noting  the  following:- — 

Points  to  he  Noted  while  Mal-ing  an  Exploratory  Puncture. — The  skin 
sliould  be  washed  with  soap  and  water,  dried,  and  again  washed  with  alcohol, 
and  lastly  with  ether.  The  needle  should  be  l)oiled  al)out  five  minutes  beh^re 
iteing  used. 

If  the  needle  is  introduced  on  the  right  side,  due  allowance  must  be 
made  for  dullness  in  the  region  occupied  by  the  liver.     Do  not  introduce 


468 


DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 


the  needle  too  near  the  region  of  the  spine,  l»ut  choose  rather  an  intercostil 
space  in  the  axiUary  line  or  preferably  below  the  scapula  on  either  side. 
If  the  needle  is  introduced  on  the  left  side  do  not  push  it  too  forcibly  nor 
too  deeply  or  haemorrhage  may  result.  Sometimes  the  fluid  is  fibrinous  and 
will  not  readily  enter  the  caliber  of  the  needle.  If  the  needle  is  plunged 
too  far  and  enters  a  dilated  bronchus,  due  allowance  must  be  made  for  a 
purulent  secretion  which  should  not  be  mistaken  for  empyema. 


Fig.  146.— Illustrating  a  Severe  Localized,  ilight-sided  Empyema.  Two 
ribs  were  resected.  The  child  made  a  complete  recovery.  The  thorax  shows 
very  slight  deformity  after  the  operation.      (Oiiginal.) 

Prognosis. — This  depends  upon  the  general  condition  at  the  time  of 
the  operation.  If  the  tubercle  bacillus  is  found  in  the  pus  the  prognosis  is 
bad.  The  longer  the  disease  existed  the  more  doubtful  the  prognosis.  If 
the  condition  is  a  sequela  to  a  pneumonia  or  a  pleurisy  then  the  prognosis 
is  good. 

Course. — The  tendency  of  empyema  in  a  child  is  to  recovery.  Out  of 
20  cases  operated  by  me,  18  recovered  in  four  to  five  weeks.  One  case 
recovered  after  six  months  of  continued  surgical  treatment,  and  was  op- 
erated three  times.  One  case  was  ill  over  two  years,  tubercle  bacilli  being 
found.    This  case  belonged  to  the  tuberculous  type  of  empyema. 


EMPYEMA.  469 

Surgical  Treatment. — When  pus  is  located,  the  indication  is  to  remove 
it.  An  incision  should  be  made  at  least  two  inches  long  through  the  skin, 
and  parallel  with  the  rib.  If  the  pus  is  thin  in  character  a  simple  inter- 
costal incision  carried  into  the  pleura  will  evacuate  the  same.  If  the  pus 
contains  fibrinous  coagula,  it  is  better  to  resect  one  or  two  ribs.  Care  must 
be  taken  to  preserve  the  periosteum  in  resecting  the  ribs.  By  this  latter 
method  we  have  complete  drainage,  and  if  the  case  is  treated  on  general 
aseptic  principles  with  drainage,  gauze,  and  restorative  treatment,  the  out- 
come is  usually  good. 

Points  to  be  noted  in  empyema  cases: — 

1.  Ancesthetic. — Do  not  use  general  anaesthesia  if  cyanosis,  marked 
dyspnoea,  or  other  severe  toxic  symptoms  are  present. 

Local  anaesthesia,  such  as  chloride  of  ethyl  or  cocaine,  can  be  used. 
I  have  frequently  operated  with  the  aid  of  chloride  of  ethyU 

2.  Regarding  Antisepsis. — When  pus  is  located  we  must  resort  to  the 
usual  details  of  asepsis  and  antisepsis.  The  instruments  should  be  rendered 
thoroughly  aseptic  and  the  child  should  be  given  a  bath  on  the  day  of 
operation  in  addition  to  a  thorough  scrubbing  of  the  seat  of  operation. 

The  physician,  if  a  general  practitioner,  should  be  extremely  careful 
and  not  operate  if  he  has  been  in  contact  with  an  acute  infectious  case; 
neither  should  he  operate  if  he  has  a  case  of  erysipelas  or  diphtheria  under 
his  care. 

While  the  pus  is  being  evacuated,  turn  the  child  from  side  to  side, 
to  empty  the  pleural  cavity.  If  the  heart's  action  is  poor  this  should  not 
be  done. 

A  large-sized  drainage  tube  should  be  inserted  into  the  wound.  The 
pleural  cavity  should  not  be  washed  with  any  fluid.  Some  authors  advise 
using  warm  salt  solutions.  It  is  important  to  have  a  cross-section  of  rubber 
tube  or  a  large  safety  pin  attached  to  the  drainage  tube,  otherwise,  as  has 
already  happened,  the  tube  may  be  lost  in  the  cavity. 

The  following  case  will  illustrate  peculiar  symptoms  shown  in  some 
cases  of  empyema: — 

A  male  child,  4  years  old,  was  brought  to  my  office  by  Dr.  M.  Freid,  with  the 
following  clinical  history:  The  child's  appetite  is  poor.  He  does  not  sleep  well,  and 
has  a  peculiar  waddling  gait.  The  left  shoulder  blade  protrudes  so  that  a  decided 
deformity  is  noticeable.      There  was  no  further  history. 

An  examination  of  the  child  showed  marked  emaciation.  Temperature  100  Vb" 
F.,  pulse  120,  respiration  38,  breathing  labored,  heart  sounds  weak  but  clear.  On 
percussion  there  was  marked  dullness  and  flatness  over  the  central  and  upper  lobe 
of  the  lung  on  the  left  side.  An  exploratory  puncture  made  about  the  eighth  inter- 
costal space  showed  pus.  Owing  to  the  weakened  state  of  the  child  it  was 
necessary  to  operate  without  an  anfesthetic.  Ethyl  chloride  was  used,  an  incision 
made,  and  two  ribs  resected.  Thorough  drainage  was  n^intained  with  the  aid  of  a 
drainage  tube,  and  with  the  addition  of  restorative  treatment,  the  case  made  an 
uneventful  recovery. 


470 


DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 


Treatment. — The  treatment  consists  in  building  up  the  system  with 
tonics  of  iron,  h3^pophosphites,  codliver-oil,  malt,  sea-salt  bathing,  and 
fresh  air,  in  addition  to  a  nutritious  diet,  of  which  milk,  eggs,  and  ceieais 
should  form  the  bulk. 

Stimulation  will  be  urgently  required.  In  other  words,  our  aim  should 
be  to  build  up  the  body  to  withstand  the  shock  of  the  operation,  and  at  the 
same  time  to  nourish  and  restore  the  general  weakened  condition. 

After-treatment. — Strict  asepsis.  Change  dressings  daily.  Use  clean 
drainage  tube  and  fresh  gauze.  Eemember  the  danger  of  iodoform  poison- 
ing in  using  large  strips  of  iodoform  gauze. 

Give  nutritious  food.  Sometimes  a  change  of  air  to  the  mountains  or 
seashore  will  aid  in  recovery. 

Eemember  that  10  per  cent,  of  all  cases  in  which  a  simple  incision 
is  made  do  not  require  after-treatment.  Ninety  per  cent,  of  cases  require 
resection  of  the  ribs  and  frequently  additional  surgical  treatment  for  chronic 
empyema. 


Fig.  147. — James  Apparatus  for  Expanding  the  Lungs  in  Empyema. 

James  Apparatus. — Pulmonary  gymnastics,  such  as  inspiration  and 
expiration,  should  be  frequently  practiced  to  aid  in  the  expansion  of  the 
lung  after  an  operation  for  empyema.  A  clever  device  is  known  as  the 
James  apparatus,  by  which  a  colored  liquid  can  be  blown  from  one  bottle 
into  another.  This  may  be  given  to  the  child  as  a  toy,  and  is  very  valuable 
as  a  means  of  producing  deep  inspiration  and  expiration. 


Chronic  Empyema. 

Neglected  cases  or  those  of  long  standing  frequently  require  additional 
treatment.  Adhesions  will  frequently  form  preventing  the  normal  expan- 
sion of  the  lung,  A  small  opening  or  sinus  containing  exuberant  granula- 
tions will  be  seen.  In  some  cases  seen  by  me  pus  has  oozed  for  months.  In  a 
case  of  this  kind  nothing  will  do  as  well  as  a  radical  operation  such  as 


TUBERCULAR  EMPYEMA.  471 

Estlander  recommended  (thoracoplasty).  The  adhesions  must  be  broken 
up  and  thorough  drainage  allowed.  When  such  a  radical  operation  is  per- 
formed, deformity  usually  follows.    These  cases  belong  to  the  surgeon. 

Tubercular  Empyema. 

This  condition  while  rare  has  been  seen  by  me  twice  during  the  last 
five  years.  It  is  found  in  families  where  tuberculosis  exists.  We  must 
bear  in  mind  that  a  tubercular  empyema  may  be  the  complication  of  what 
was  formerly  a  non-tubercular  type. 

Environment  and  heredity  play  an  important  part  in  the  etiology  of 
this  condition.  Just  as  a  tuberculosis  may  follow  the  broncho-pneumonia 
of  measles,  so  I  believe  that  tubercular  empyema  may  also  develop.  The 
following  case  will  illustrate  this  condition  as  seen  by  me  in  consultation 
in  New  York  City: — 

M.  J.,  5  years  old,  was  referred  to  me  by  Dr.  Mehrenlander,  with  a  history  of 
cough,  fever,  and  emaciation.  The  diagnosis  of  empyema  was  made  and  an 
exploratory  puncture  showed  the  presence  of  pus.  With  the  assistance  of  Dr. 
Mehrenlander  I  performed  a  thoracotomy.  As  there  were  thick  croupous  masses, 
two  ribs  were  resected  and  a  drainage  tube  inserted.  In  this  case  the  wound 
discharged  several  months  and  an  examination  of  the  pus  showed  the  presence  of 
tubercle  bacilli.  With  the  aid  of  fresh  air  and  restoratives,  such  as  codliver-oil, 
creosote  carbonate,  and  special  attention  to  the  out-door  life,  the  child  recovered. 

Family  History. — The  child's  father  and  mother  are  living.  Their  occupation 
is  janitor  and  janitress  in  a  tenement  house.  They  receive  in  compensation  for 
services  free  rent,  so  that  gives  them  very  unsanitary  surroundings.  The  bedrooms 
are  dark  and  very  unsanitary.  An  older  brother,  17  years  of  age,  has  acute  apical 
tuberculosis.  This  older  brother  when  brought  to  me  for  a  slight  cough  showed 
no  visible  evidence  of  disease,  in  fact  he  appeared  well  nourished.  His  sputum  con- 
tained tubercle  bacilli.  We  therefore  have  in  the  two  cases  just  described  a  tuber- 
cular empyema  associated  with  family  tuberculosis.  The  coexistence  of  empyema  and 
a  family  history  of  tuberculosis  strengthened  my  opinion,  that  living  under  the  same 
unsanit?ry  conditions  and  associating  together,  these  cases  were  most  probably 
transmitted  or  communicated. 


PART  VII. 

THE  INFECTIOUS  DISEASES. 


CHArTEil  J. 


fevp:r.' 

This  is  a  pathological  process  generally  caused  by  the  poisonous  prod- 
ucts of  bacteria,  and  characterized  by  a  rise  of  temperature  above  the  limit 
of  the  daily  variation.  It  is  further  associated  with  an  increase  in  the  fre- 
quency of  the  heart  and  the  respiratory  movements,  often  with  an  increase 
in  excretion  of  urea  and  ammonia  in  the  urine  and  a  diminution  in  the 
alkalies  and  COg  in  the  blood. ^ 

Some  authors  state  that  the  cause  of  fever  is  the  action  of  bacterial 
poison  or  of  other  substances  on  the  heat  centers,  and  that  antipyretics  or 
drugs  which  reduce  the  temperature  in  fever,  do  so  by  restoring  the  centers 
to  their  normal  state  by  preventing  the  development  of  the  poisons,  aiding 
their  elimination,  or  antagonizing  their  action.  Thus  it  has  been  stated 
(supporting  the  latter  view)  that  if  the  basal  ganglia  have  been  cut  off 
(by  section  of  the  pons)  from  their  lower  nervous  connections,  fever  is  no 
longer  produced  by  injection  of  cultures  of  bacteria  which  readily  cause  it 
in  an  intact  animal — while  antipyrine  has  no  influence  on  the  temperature. 
These  experiments  were  reported  by  Sawadowski. 

Some  observers  have  been  unable  to  find  any  clear  evidence  of  heat 
centers;  that  is,  of  localized  portions  of  the  central  nervous  system  specially 
concerned  in  the  regulation  of  the  body  temperature. 

It  is  almost  certain  that  some  pyrogenie  or  fever-producing  agent — 
cocaine,  for  example — acts  indirectly  through  the  brain  or  cord,  and  likely 
others  affect  directly  the  activity  of  the  tissues  in  general,  just  as  some 
antipyretics  or  fever-reducing  agents,  such  as  quinine,  seem  to  act  imme- 
diately upon  the  heat-forming  tissues,  while  antipyrine  affects  them  through 
the  nervous  system. 

Variations  in  Temperature."' — The  temperature  of  the  body  is  not  con- 
stant. It  varies  with  the  time  of  day,  with  eating,  with  age,  somewhat 
with  violent  changes  in  the  external  temperature  (hot  or  cold  baths),  and 
even  possibly  with  sex. 


*  For  treatment  of  fever,  see  pages  511  and  512. 

*  Stewart's  Physiology,  p.  443.     Article  on  "Animal  Heat." 

'Tlie  temperature  as  a  diagnostic  aid  is  described  in  Part  I,  page  11. 
(472) 


FEVER.  473 

The  lowest  temperature  is  recorded  between  2  and  6  a.m.  The  highest 
at  5  to  8  P.M.  There  is  a  corresponding  fluctuation  of  pulse-rate  at  the  same 
time  of  day. 

Taking  of  food  increases  the  temperature,  but  not  more  than  one-half 
of  a  degree  in  healthy  individuals.  Entrance  of  food  into  the  body  in- 
creases metabolic  activity,  no  doubt,  through  entrance  of  products  of  diges- 
tion into  the  blood. 

Sex. — Females  usually  have  higher  temperature  than  males. 

Relation  of  Age  to  Temperature. — There  is  a  relative  imperfection 
between  heat  regulation  in  old  people  and  young  children;  thus,  young 
children  are  more  liable  to  sudden  increase  in  temperature  as  well  as  to 
chills.  A  fit  of  crying  will  send  up  the  temperature.  Sudden  fright  (slam- 
ming a  door)  will  send  up  the  temperature  (J.  L.  Smith). 

Mosso  reports  that  the  rectal  temperature  rose  three  degrees  in  a  dog 
rendered  helpless  with  injections  of  curare.  When  injections  of  strychnine 
were  given,  this  latter  (strychnine)  no  doubt  irritated  the  nervous  system. 
Pie  found  that  the  presence  of  food  was  enough  to  cause  the  rise  in  the 
temperature  of  the  dog. 

Thus  we  find  that  the  usual  fever-causing  factors  are : — 

1.  Toxins. 

2.  Ferments. 

3.  Products  of  waste  which  are  absorbed  in  the  lymphatics  (detritus). 

We  know  that  the  regulation  of  the  heat  is  brought  about  by  the  cen- 
tral nervous  system,  and  we  also  know  the  influence  brought  about  by  the 
vasomotor  (nervous  system)  in  dilating  and  contracting  the  capillaries. 

The  discovery  of  Aronsohn  and  Sachs,  that  by  traumatism  or  irritation 
of  the  corpus  striatum,  an  elevation  of  temperature  is  produced,  is  still 
a  question,  doubted  by  many  distinguished  observers.  But  it  certainly 
does  look  as  though  a  certain  center  or  centers  exist  which  influence  the 
body  temperature. 

Knowing  then  that  other  agencies  besides  disease  cause  an  elevated 
temperature,  the  question  arises:  are  we  justified  in  designating  every  rise 
of  temperature  as  "fever?"  Hardly.  An  elevation  of  temperature  (above 
normal)  should  be  designated  as  "hyperthermia."  We  know  that  the 
fever  is  caused  by  the  absorption  of  infectious  products  which  later  cause 
a  breaking  down  and  loss  of  the  red  blood  corpuscles,  breaking  down  of  the 
tissues,  and  disintegration  of  albumin  and  its  compounds,  and  produce 
symptoms  pointing  to  distinct  disorders  in  the  human  economy.  Some 
authors  have  described  fever  under  two  headings  or  divisions: — 

1.  Septic. 

2.  Aseptic. 

As  an  example  of  a  septic  fever,  we  have  that  chronic  poisoning  of  the 
human  organism  which  takes  place  in  chronic  pulmonary  tuberculosis,  and 


474  THE  INFECTIOUS  DISEASES. 

even  in  this  latter  toxsemic  process  we  find  sudden  rises  of  temperature, 
which  must  be  explained  by  emotional  means,  or  rather  by  nervous  causes. 
In  a  tuberculous  patient  whose  system  is  overwhelmed  with  toxins  (chronic 
and  continuous  poisoning)  we  can  readily  understand  why  the  thermic 
centers  as  well  as  all  other  centers  could  be  easily  influenced  to  cause  a 
sudden  rise  in  temperature  responding  to  a  slight  emotion  or  fright. 

Let  us  now  consider  so-called  "nervous''  or,  as  it  has  been  designated, 
'^hysterical  fever."  The  latter  term  we  owe  to  the  French  authors  ( Pomme, 
Toussot,  Baillon,  Eiviere).  By  this  we  mean  a  febrile  condition  which  is 
not  caused  by  any  inflammatory  or  other  disease  agency,  and  which  is 
found  in  either  very  nervous,  neurasthenic,  or  hysterical  patients. 

Broussois  (France)  opposed  this  theory  and  believed  this  condition 
due  chiefly  to  inflammatory  changes  in  the  ovary  and  uterus. 

Briquet  showed  by  careful  examination  the  fallacy  of  the  foregoing 
statements  in  a  series  of  noteworthy  investigations. 

In  1888  Chaveau,  in  Paris,  wrote  a  careful  dissertation  called  "Fi^vre 
Hysterique,"  and  divided  this  condition  into  several  distinct  groups.  A 
characteristic  point  is  the  absence  of  gastric  disturbance  (digestive),  show- 
ing that  it  was  not  a  malignant  disturbance. 

Chaveau  looked  to  the  cause  of  his  cases  in  an  abnormal  excitation  of 
the  thermic  center  in  sensitive  (nervous)  individuals.  An  accompanying 
factor  he  believes  to  be  either  traumatic  or  psychic  disturbances. 

Wunderlich  (Germany)  long  ago  called  attention  to  the  fact  that 
hysteria  influences  the  temperature,  and  that  in  hysterical  neurosis  we  find 
sudden  elevations  of  temperature.  It  is  a  remarkable  fact  and  one  noted 
by  many  others,  that  one  side  of  the  body  shows  this  high  temperature 
without  any  pathological  condition  manifesting  itself. 

Eosenthal  (Vienna)  found  distinct  localized  areas  of  redness  with 
marked  rise  of  temperature  in  this  area,  but  found  no  general  febrile 
disturbance.  The  patient  was  decidedly  hysterical.  Strumpell  agrees  that 
he  has  found  very  high  temperatures,  irregularly,  but  believes  the  patients 
simulated  their  marked  hysterical  and  irritable  condition. 

Ewald  (Berlin)  agrees  that  hysterical  patients  can  produce  high  fever 
by  reason  of  their  excitement. 

Hale  White  (England)  doubts  that  the  thermogenetic  functions  should 
cause  high  fever,  and  cites  instances  which  were  known  as  hysterical  paral- 
ysis. 

Cleman  reported  in  the  Clinical  Society  of  London,  1883,  a  case  of 
hysterical  fever,  showing  the  enormous  temperature  of  111°  F.  at  various 
times. 

Hale  White  believed  that  a  mistake  in  reading  the  thermometer  was 
made. 

TJghetti  believes  hysterical  fevers  exist,  and  cites  as  proof  of  the  same 
fever  in  course  of  hysteria,  chorea,  epilepsy,  and  Basedow's  disease. 


FEVER. 


475 


The  greatest  scientific  contribution  on  this  subject  has  certainly  been 
the  work  of  A.  Sarbo  in  the  University  of  Psychiatrie  and  Nervous  Dis- 
eases in  Budapest.^  He  believes  as  a  result  of  experimental  study,  that 
the  causation  of  fever  should  be  looked  forward  to  in  the  "central  nervous 
system/'  and  that  the  experimental  discoveries  of  the  thermic  and  vaso- 
motor centers  seem  to  confirm  this.  This  author  believes  that  fever,  which 
has  no  organic  lesion  as  a  cause,  should  be  called  functional  fever,  which 
is  a  condition  found  in  h3'steria,  the  latter,  a  functional  neurosis.  It  is 
interesting  to  record  that  Debone  increased  the  temperature  by  suggestion 
to  101.2°  F.  or  38.5*  C. 

Krafft-Ebing  records  temperatures  by  suggestion  as  high  as  106.4°  F. 

Sarbo  concludes  by  saying  that  from  his  clinical  observations  a  distinct 
hysterical  fever  exists. 

Hysterical  fever  can  simulate  by  its  exacerbation  and  remission  such 
diseases  as  tj^hoid,  malaria,  tuberculosis,  and  meningitis. 


Table  No.  60. — Showinrj  the  Ratio  of  Mortntity  from  Infectious  Diseases  of  Children 
Under  Two  Years  of  Age  in  New  York  City. 


Males. 

" 

Tubercular  Diseases    .    . 

294 

678 

322 

304 

198 

297 

253 

252 

256 

210 

219 

192 

Diphtheria  and  Croup  . 

333 

843 

861 

398 

376 

377 

337 

278 

201 

195 

219 

236 

Measles 

260 

198 

317 

142 

204 

251 

218 

133 

188 

141 

155 

90 

Whooping   Cough    .    .    . 

164 

137 

122 

205 

74 

172 

154 

99 

167 

132 

107 

53 

Scarlet  Fever       .... 

44 

145 

102 

64 

67 

50 

46 

66 

66 

37 

62 

58 

Phthisis  Pulmonalis   .    • 

54 

42 

61 

58 

49 

74 

50 

52 

47 

53 

50 

44 

Typhoid  Fever 

3 

4 

5 

3 

3 

5 

2 

0 

1 

1 

4 

3 

YE4R      

1890  1  1891 

1 

1892 

1893 

1894 

1895 

1896 

1897 

1         1 

1898     1899     1900 

1901 

Females. 

Typhoid  Fever 

2 

3 

4 

2 

2 

1 

2 

2 

1 

0 

2 

2 

Phthisis  Pulmonalis  .    . 

54 

41 

50 

40 

m 

53 

42 

40 

25 

41 

21 

35 

Scarlet  Fever              .    . 

54 

121 

113 

63 

53 

53 

37 

48 

58 

40 

28 

56 

Whooping  Cough    .    .    . 

212 

140 

102 

221 

121 

219 

179 

139 

186 

139 

123 

72 

Measles 

240 

232 

261 

121 

182 

265 

221 

134 

136 

125 

157 

72 

Diphtheria  and  Croup  . 

259 

287 

289 

283 

410 

310 

202 

287 

130 

201 

172 

200 

Tubercular  Disease^s 

228 

361 

251 

243 

214 

220 

201 

223 

213 

213 

189 

146 

Note. — Various  statistics  and  temperature  charts  were  procured  from 
the  wards  of  the  Riverside  Hospital  with  the  kind  assistance  of  Dr.  Watson, 
the  resident  physician. 

I  am  also  indebted  to  Dr.  Henry  L.  Lynah  for  similar  courtesies  in  the 
wards  of  the  Willard  Parker  Hospital. 

I  am  indebted  to  Dr.  William  H.  Guilfoy,  Registrar  of  the  New  York 
Health  Department,  for  many  courtesies  in  the  preparation  of  the  statis- 
tics of  the  various  infectious  diseases. 


*  Published  in  the  Archiv  ftir  Psychiatrie  in  1891. 


476 


THE  INFECTIOUS  DISEASES. 


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TABLE   OF  INFECTIOUS   DISEASES. 


477 


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Lungs. 

Heart. 

Kidneys. 

ICars. 

Brain. 

I'aralysis. 

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Blood. 
Lungs. 
Heart. 
Peritoneum. 

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Sore      throat,      weakness, 
lever.   Pain  on  swallowing. 
Older  children  complain  of 
headache. 

Cough  during  first  week  of 
infection    resembles    bron- 
c  h  i  t  i  s.        Characteristic 
cough,  often  not  seen  until 
second  week.     Vomiting. 

Pain  on  chewing,  inability 
to  swallow. 

Diarrhoea  or  constipation. 
Sometimes  convulsions. 
Enlarged  spleen,     fhirst. 
Prostration.     Delirium. 

a' 

Enlargetl  spleen.      Convul- 
sions.   Prostration.     Drow- 
siness.    Voniiling. 

Cachexia.     Wasting. 
Coryza.    Onychia. 
Diarrhoea. 

Prostration.    Fever.    Vom- 
iting.    Diarrhoea,    Convul- 
sions. 

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A  lone  paroxysm  of  cough- 
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Ms 

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Rose-colored,       lenticular- 
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beginning   of    the    second 
week.     Eruption   lasts  6  to 
10  days.      Fever,   step-lad- 
der type. 

it 

53 

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Eruption  sometimes  diffuse, 
flush  or  roseolar,  more  fre- 
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in  dark  red  spots  about  the 
size  of  an   infant's   tooth. 
Occur  mostly   on   face  and 
extremities. 

Painful  -welling  at  extremi- 
ties of  long  bones.  Pseudo- 
paralysis. 

Painful  swelling  of  the  lym- 
phatic glands  of  the  region 
involvel.    Intense  red  color 
of  the  region  involved. 

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478 


THE  INFECTIOUS  DISEASES. 


Tabt.r  No.  Q2.—8fiomng  Ratio  of  Mortality  from  Infectious  Diseases  in  Children 
Between  the  Ages  of  Two  and  Five  in  New  York  City. 


Males. 

Diphtheria  and  Croup   . 

430 

494 

580 

617 

731 

477 

405 

350 

190 

240 

297 

275 

Scarlet  Fever 

99 

319 

244 

142 

127 

149 

106 

127 

119 

83 

77 

151 

Measles 

105 

95 

113 

47 

70 

105 

118 

52 

58 

45 

67 

48 

Tubercular  Diseases 

82 

72 

81 

92 

82 

86 

98 

86 

85 

89 

90 

67 

Whooping   Cough 

40 

28 

32 

39 

26 

38 

29 

31 

28 

25 

32 

11 

Phthisis  Pulmonalis   .    . 

22 

19 

24 

26 

24 

22 

13 

13 

9 

24 

29 

20 

Typhoid    Fever 

5 

9 

7 

4 

2 

3 

7 

5 

4 

2 

6 

8 

Ykab 

1890 

1891 

1892 

1893 

1894 

1895 

1896 

1897 

1898 

1899 

1900 

1901 

Females. 

Typhoid   Fever            .    . 

4 

8 

2 

4 

8 

8 

3 

5 

8 

2 

6 

7 

Phthisis  Pulmonalia  .    . 

21 

16 

23 

27 

20 

16 

21 

23 

19 

26 

18 

18 

Whooping   Cough    .    .    . 

56 

39 

45 

59 

43 

50 

57 

31 

51 

46 

41 

19 

Measles 

87 

102 

122 

59 

85 

182 

116 

50 

49 

46 

55 

40 

Tuberculosis 

85 

74 

77 

72 

83 

98 

79 

66 

65 

80 

65 

71 

Scarlet  Fever       .... 

102 

302 

235 

127 

136 

105 

105 

124 

151 

81 

62 

138 

Diphtheria  and  Croup  . 

432 

465 

494 

612 

701 

449 

430 

254 

203 

257 

279 

273 

Table  No.  63. — SJiowing  the  Ratio  of  Mortality  from  Infectious  Diseases  of  Children 
Between  the  Ages  of  Five  and  Ten  in  New  York  City. 


Males. 

Diphtheria  and  Croup  . 

151 

163 

160 

226 

249 

146 

130 

128 

65 

74 

131 

95 

Scarlet  Fever  .    . 

55 

136 

118 

69 

58 

42 

53 

69 

56 

38 

38 

100 

Tubercular  Diseases  .    • 

31 

38 

33 

44 

51 

34 

41 

43 

37 

29 

35 

47 

Phthisis  Pulmonalia 

22 

30 

24 

35 

35 

21 

24 

28 

28 

33 

29 

30 

Measles      

16 

18 

18 

9 

20 

15 

16 

6 

6 

16 

15 

14 

Typhoid  Fever 

9 

12 

10 

12 

9 

6 

11 

7 

9 

3 

11 

6 

Whooping  Cough 

7 

3 

2 

6 

3 

5 

6 

2 

3 

1 

4 

1 

Yeab 

1890 

1891 

1892 

1893 

1894 

1895 

1896 

1897 

1898 

1899 

1900     1901 

1 

Females. 

Whooping  Cough    •    .    • 

6 

4 

8 

12 

5 

10 

10 

1 

6 

6 

9 

2 

Typhoid    Fever    .... 

8 

14 

14 

7 

-  6 

6 

18 

9 

7 

8 

-  6 

4 

Measles 

16 

12 

27 

11 

15 

20 

16 

12 

5 

5 

15 

6 

Tubercular  Diseases   .    . 

84 

46 

40 

42 

49 

42 

41 

38 

36 

47 

88 

36 

Scarlet  Fever 

45 

165 

131 

68 

72 

57 

52 

59 

56 

48 

82 

102 

Phthisis  Pulmonalis    .    . 

70 

62 

61 

67 

47 

53 

56 

41 

48 

50 

48 

53 

Diphtheria  and  Croup  . 

152 

182 

185 

283 

275 

181 

167 

170 

103 

86 

138 

115 

Table  No.  64. — Showing  Percentage  of  Deaths  from  Infectious  Diseases  in  Children 
Under  Ten  Years,  from  1890  Until  19Gg,  in  New  York  City. 


1  MALES. 

FEMALES. 

Died. 

Per  cent. 

Died. 

Per  cent. 

Typhoid  Fever 

317 
1,228 
1,928 
8,357 
3,394 
10,576 
4,857 

.006 
.024 
.038 
.066 
.066 
.293 
.096 

252 
1,386 
2,545 
8,104 
8,294 
10,117 
4,177 

.004 

Phthisis  Pulmonalia 
Whooping  Cough   .    . 
Scarlet  Fever  ... 

.037 
.050 
.061 

Measles.    ... 
Diphtheria  and  Croup 
Tubercular  Diseases 

.065 
.200 
.082 

CHAPTEE  II. 

INFLUENZA  (LA  GRIPPE). 

CoMMOXLY  known  as  "grip"  or  "epidemic  catarrhal  fever." 
This  is  an  acute  infections  disease  with  which  catarrhal  disturbances  of 
the  respiratory  or  gastro-intestinal  organs  are  usually  associated.     There 
is  also  a  profound  nervous  disturbance  with  marked  perspiration  and  very 
high  fever. 

The  disease  occurs  epidemically,  spreading  from  case  to  case  with 
great  rapidity,  so  that  it  was  formerly  attributed  to  meteorologic  condi- 
tions.    It  is  for  this  reason  known  and  described  by  the  Germans  as  a 


Fig.  148. — Influenza  Bacilli.  8putiim  smear,  stained  with  dilute  Ziehl's 
solution.  Bacilli  chiefly  intracellular,  most  of  them  show  thickened  ends. 
X  800.      ( Lenhartz-Brooks. ) 

"Blitzkatarrh."  The  disease  occurs  most  frequently  in  cold  and  damp 
weather,  and  frequently  attacks  the  same  person  several  times. 

Bacteriology. — The  disease  is  caused  by  a  very  small  bacillus,  about 
0.8  micro-millimeter  long  and  0.4  micro-millimeter  broad. 

This  bacillus  was  first  discovered  by  Pf'Ciffer,  in  1893.  It  stains  very 
intensely  at  the  ends  and  resembles  a  diplococcus. 

In  the  mucous  membrane  of  the  nose,  throat,  and  lungs  we  find  the 
greatest  number  of  bacilli ;  thus,  it  is  reasonable  to  suppose  that  the  in- 
fection takes  place  through  the  respiratory  tract,  and  in  this  manner  the 
germs  gain  an  entrance  into  the  body. 

The  bacillus  of  Pfeiffer  only  is  present  in  influenza.  The  poison  gen- 
erated by  this  germ  resembles  a  group  of  bacterial  proteins,  described  by 
Buchner.     Such  poisons  occur  within  germs  and  are  excreted,  but  only 

(479) 


480  THE  INFECTIOUS  DISEASES. 

to  a  limited  extent,  in  the  media  in  which  they  grow.  Examples  of  these 
germs  are  the  diphtheria  and  tetanus  bacilli.  Such  toxins  affect  the  cen- 
tral nervous  system  very  powerfully.  Thus  we  find  severe  nervous  depres- 
sion in  the  course  of  an  attack  of  influenza,  just  as  we  do  in  the  course 
of  a  severe  case  of  diphtheria.  The  influenza  bacillus  is  frequently  asso- 
ciated with  other  pyogenic  bacteria.  The  tendency  of  mixed  infection  in 
the  course  of  influenza  is  to  generate  pus.  It  is  therefore  a  wise  plan  to 
examine  the  middle  ear  for  possible  suppurative  conditions. 

Not  infrequently  tuberculosis  is  associated  with  or  follows  a  severe 
attack  of  influenza. 

Symptoms. — ^When  children  are  old  enough  to  complain,  then  one  of 
the  most  frequent  subjective  symptoms  will  be  either  a  violent  headache 
or  pains  in  the  muscles  of  the  body.  In  young  children  and  nurslings 
violent  vomiting,  associated  with  diarrhoea,  may  be  the  initial  symptoms  of 
the  disease.  While  fever  usually  accompanies  an  attack  of  influenza,  there 
are  many  cases  in  which  a  subnormal  temperature  is  present.  As  has  been 
previously  stated,  chills  or  rigors  are  seldom  or  never  present. 

Convulsions  in  young  children  are  frequently  a  forerunner  of  an  attack 
of  influenza.  The  differential  diagnosis  between  an  attack  of  measles  and 
influenza  is  sometimes  quite  difiicult.  Both  commence  with  sneezing, 
coughing,  and  catarrhal  symptoms,  with  suffused  eyes,  and  an  eruption 
resembling  measles  may  frequently  be  found  in  influenza. 

Diagnosis. — The  diagnosis  of  this  disease  is  sometimes  very  difficult. 
If  an  epidemic  exists,  or  if  several  members  in  a  family  are  attacked  with 
grip  and  the  children  suddenly  exhibit  symptoms  of  malaise  or  have  a  dis- 
ordered stomach,  and  show  high  fever  without  any  apparent  reason,  then 
influenza  should  be  suspected.  If  catarrhal  symptoms  associated  with 
influenza  present  themselves,  then  such  symptoms  are  of  a  more  sev^ere 
type  than  those  usually  seen  in  simple  coryza. 

An  eruption  resembling  scarlet  fever,  complicated  by  tonsillitis  or 
pharyngeal  symptoms,  will  baffle  the  diagnostic  ability  of  the  physician, 
but  the  presence  of  influenza  in  a  house  will  aid  in  eliminating  other  dis- 
eases and  assist  in  establishing  the  true  diagnosis.  Not  infrequently  a  child 
will  suddenly  show  high  fever  and  diarrhoea,  with  severe  nervous  depres- 
sion, intense  thirst,  and  typhoid  tongue,  with  here  and  there  small  lenticu- 
lar spots  which  may  so  resemble  typhoid  fever  that  only  the  course  of 
the  disease  and  constant  watching  will  aid  in  making  a  correct  diagnosis. 
Where  such  symptoms  exist  we  must  resort  to  an  examination  of  the  urine, 
and  it  is  here  that  the  diazo  reaction  will  render  material  assistance.  In 
addition  to  the  examination  of  the  urine,  the  Widal  reaction  should  be 
resorted  to.  If  both  the  Widal  and  the  diazo  reaction  are  absent,  and  if 
the  depression  and  catarrhal  symptoms  resembling  influenza  continue, 
then,  and  then  only,  should  the  diagnosis  of  influenza  be  made.    The  fever 


INFLUENZA. 


481 


is  more  irregular  in  the  course  of 
influenza  than  it  is  in  typhoid,  and 
usually  shows  an  evening  fall  and  a 
morning  rise,  which  is  the  reverse 
of  typhoid.  The  skin  is  usually 
very  pale  in  typhoid  and  flushed  in 
influenza.  There  are  three  definite 
types  of  influenza  most  usually  met 
with  in  children  : — 

1.  That  affecting  the  respira- 
tory tract. 

2.  That  affecting  the  gastro- 
enteric tract. 

3.  That  in  which  the  brain  and 
nervous  system  are  largely  affected. 

Respiratory  Type.  —  When  the 
respiratory  tract  is  involved  we  usu- 
ally have  either  a  pharyngitis,  ton- 
sillitis, pneumonia,  or  a  broncho- 
pneumonia. When  a  very  young 
child  shows  severe  broncho-pneumo- 
nia and  there  is  a  general  toxremia 
associated  with  it,  then  the  prognosis 
is  usually  very  bad.  A  very  frequent 
complication  in  this  condition  is  tu- 
berculosis; thus,  if  tuberculosis  fol- 
lows a  severe  attack  of  influenza  in 
a  young  child  whose  system  is  un- 
dermined from  a  long  and  tedious 
disease,  then  grave  results  may  fol- 
low. 

Gastro-enteric  Type.  —  In  very 
young  children  this  is  the  most  fre- 
quent form  of  influenza.  Vomiting 
and  diarrhoea,  usually  accompanied 
by  fever,  will  be  found.  The  child 
will  suddenly  refuse  to  take  the 
breast,  if  it  is  a  nursling,  or  refuse 
to  take  bottle  if  it  is  hand-fed.  It 
will  also  show  great  restlessness  and 
seem  dissatisfied  and  peevish. 
The  sleep  will  be  disturbed,  so  that 
insomnia  is  a  very  frequent  symp- 
tom.     In  spite  of  careful  dietetic 


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Fig.  149.— Case  of  Influenza  Pneu- 
monia. Child  about  eight  months  old. 
Suirercd  severe  prostration  from  the 
toxsemia.  Note  the  very  high  pulse-rate. 
Treatment  consisted  in  using  steam  im- 
l)regnated  with  bcechwood  creosote,  mild 
laxative  and  careful  diet.  Case  recov- 
ered.     (Original.) 


482  THE  INFECTIOUS  DISEASES. 

treatment  and  a  thorough  cleansing  of  the  gastro-intestinal  tract,  the  child 
will  show  the  same  clinical  picture  in  mid-winter  as  we  are  familiar  with  in 
the  course  of  a  severe  type  of  summer  complaint  in  mid-summer.  Convul- 
sions are  frequent,  though  not  always  present.  Such  children  suffer 
severely,  owing  to  the  malnutrition  and  owing  to  the  extreme  exhaustion 
following  a  continued  vomiting  or  diarrhcea.  They  lose  flesh  and  resemble 
the  atrophied  condition  following  an  acute  summer  complaint. 

Nervous  Type. — This  is  usually  the  most  serious  form  of  the  disease, 
involving  as  it  does,  the  brain  and  the  nervous  system.  In  this  type  we  meet 
with  extreme  irritability,  and  if  the  child  is  old  enough  to  complain  then 
headache  forms  a  prominent  symptom,  so  also  will  pains  in  the  limbs  and 
in  all  the  muscles  of  the  body  be  complained  of.  Twitching  is  sometimes 
a  marked  symptom;    convulsions  are  very  frequent. 

If  the  case  of  influenza  is  the  only  one  in  the  family  the  physician  may 
believe  that  he  is  dealing  with  a  meningitis.  Such  symptoms  as  photo- 
phobia, stupor,  coma,  retraction  of  the  head,  are  frequently  present; 
the  pulse  is  rapid,  the  temperature  is  frequently  very  high,  although  the 
usual  temperature  ranges  between  101°  and  103°  F.  When  severe. toxaemia 
exists  it  is  not  infrequent  to  find  a  subnormal  temperature. 

Complications.  —  Empyema  sometimes  complicates  influenza.  Some 
authors  believe  that  it  rarely  exists,  whereas  during  a  recent  epidemic  the 
writer  saw  at  least  one  dozen  cases  of  influenza  complicated  by  empyema. 
The  same  may  be  said  of  otitis  media;  thus  a  suppurative  middle  ear  dis- 
ease was  noted  a  great  many  times  during  the  course  of  the  epidemic  in 
1903. 

J.  Madison  Taylor  contends  that  neuritis  rarely  follows  influenza  in 
children,  whereas  it  is  a  common  sequel  in  adults. 

Nephritis  occasionally  complicates  influenza. 

Milton  Miller^  reports  40  cases  of  influenzal  nephritis  taken  from 
literature.  He  reports  a  very  interesting  case  of  a  child  that  had  persistent 
vomiting  and  slight  diarrhcea;  later  on  oedema  of  the  limbs  and  suppres- 
sion of  urine. 

The  course  of  influenza  in  children  is  hard  to  define.  Some  children 
will  be  ill  a  week  or  ten  days;  others  will  show  the  evidence  of  systemic 
infection  months  after  an  attack  commenced.  For  this  reason  every  case 
of  influenza  should  be  carefully  supervised  during  the  convalescence. 

Prognosis. — This  depends  on  the  condition  of  the  child  prior  to  an 
attack.  If,  for  example,  an  infant  nursing  at  the  breast  is  attacked  with 
a  severe  form  of  influenza,  then  the  prognosis  may  be  reasonably  good.  If, 
however,  the  'Tjottle  baby,"  with  an  existing  rickets,  is  attacked  in  a  similar 
manner,  then  the  prognosis  is  certainly  much  worse  than  it  would  be  other- 
wise; thus  the  general  systemic  condition  prior  to  the  infection  of  the  grip 

^  Archivea  of  Pediatrics,  January,  1902. 


I 
I 


INFLUENZA. 


483 


will  usually  suggest  the  probable  outcome  of  the  disease.  On  the  other  hand 
a  strong,  robust  child,  having  a  severe  form  of  influenza,  complicated  by 
middle-ear  disease,  with  mastoid  or  cerebral  complications,  necessarily  means 
a  bad  prognosis.  The  same  rule  would  apply  to  all  complications  following 
an  attack  of  influenza,  in  which  exhaustion  from  a  lengthy  attack,  besides 
the  difficulty  of  properly 
feeding  and  sustaining 
life,  would  invite  a  fatal 
termination. 

The  sheet  anchor  of 
success  would  be  the 
good  condition  of  the 
heart,  the  exclusion  of 
kidney  complication,  and 
also  the  fact  that  the 
infant  takes  a  reasonable 
quantity  of  food.  A  pro- 
gessive  weakness  of  the 
heart  or  the  devitalized 
state  of  the  blood  from 
prolonged  pneumonia 
would  mean  a  grave  prog- 
nosis; thus  all  would 
depend  on  limiting  the 
extent  of  the  disease  and 
the  avoidance  of  compli- 
cations. 

Treatment. — In  a 
case  of  grip  it  is  advis- 
able to  isolate  the  child 
affected  from  the  other 
children  in  the  family. 
Next  to  isolation  the 
child  must  be  put  to 
bed  and  kept  warm. 
It  is  advisable  to  give 
a  mustard  foot-bath  to 
stimulate  the  circulation,  and  follow  this  up  by  keeping  either  a  hot  water 
bag  or  bottles  of  hot  water  to  the  feet.  If  the  head  is  very  hot  an  ice-bag 
or  cold,  applied  by  ice-cold  handkerchiefs  to  the  head  in  the  region  of 
the  fontanels,  would  be  indicated.  If  high  fever  exists  then  15  to  30  drops 
of  sweet  spirits  of  niter,  repeated  three  times  in  intervals  of  one  hour,  will 
not  only  aid  the  kidneys,  but  also  have  a  slight  diaphoretic  effect 


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Fig.  150. — Case  of  Influenza  Pneumonia  in  a 
Child  Two  Years  Old.  Note  the  irregular  type  of 
fever  and  compare  the  steady  heart's  action  as  indi- 
cated by  the  pulse.    Child  recovered.     (Original.) 


484  THE  INFECTIOUS  DISEASES. 

A  favorite  formula  of  miue  is  tincture  aconite  rad.,  1  drop,  combined 
with  spiritus  mindereri,  ^/.,  teaspoonful,  freshly  prepared,  and  kept  in  a 
cool  place.  The  above  to  be  given  every  hour  until  the  temperature  is 
reduced  or  until  perspiration  appears. 

The  stomach  and  bowels  require  very  careful  attention  in  the  gastric 
type  of  this  disease;  thus  a  good  plan  is  to  commence  by  giving  a 
small  tablet,  containing  Vk,  grain  of  calomel,  with  a  little  water,  every 
hour  for  six  doses,  or  until  the  effect  of  the  calomel  is  manifested  by  the 
greenish  stools. 

If  the  child  is  old  enough  then  small  pieces  of  cracked  ice  or  ice  cream 
may  be.  given  for  several  hours.  If  vomiting  persists  after  the  ice  cream 
then  nothing  should  be  given  by  mouth  for  six  hours. 

During  such  time,  when  there  is  severe  irritability,  medication  may  be 
given,  either  in  the  form  of  rectal  suppositories,  or,  if  possible,  by  hypo- 
dermic means. 

An  ice-bag  applied  at  the  pit  of  the  stomach  will  frequently  arrest 
vomiting.  An  ether  spray  over  the  epigastrium  for  a  minute  will  some- 
times relieve  a  persistent  vomiting. 

Liquid  food  in  a  concentrated  form,  such  as  broths,  soups  and  cereals, 
steak  juice,  raw  beef  juice,  white  of  egg  and  water,  or  the  yolk  of  an  egg 
added  to  concentrated  soup,  is  very  nourishing  if  the  stomach  can  retain 
the  same.  Calisaya  is  one  of  the  best  tonics.  If  the  stomach  is  not  irri- 
table nitroglycerine,  in  doses  of  V200  grain,  will  do  good. 

Strychnine,  persistently  given,  is  indicated  in  the  course  of  convales- 
cence just  as  it  is  indicated  in  diphtheria. 

Peptonized  foods,  chiefly  milk  and  peptonized  broth,  may  be  neces- 
sary if  we  are  dealing  with  a  prolonged  gastric  type  of  the  disease  with  sub- 
normal digestive  power.  When  convalescence  is  established  then  syrup  of 
hypophosphites,  or  phosphorus  combined  with  codliver-oil,  or  the  glycero- 
phosphate of  lime,  will  be  found  advantageous. 

No  matter  how  slight  an  attack  of  influenza  has  been  encountered  it  is 
well,  when  convalescence  is  permanently  established,  to  insist  on  a  change 
of  air  to  the  South,  if  in  winter,  to  such  places  as  Virginia  Bay,  Old  Point 
Comfort,  or  Florida,  or  if  in  the  summer  to  places  like  Lakewood,  or, 
better  still,  Atlantic  City.  If  we  have  encountered  a  severe  form  of  this 
disease  with  extreme  emaciation  and  loss  of  tone,  then  a  radical  change  of 
air  to  a  more  balmy  and  permanent  climate,  such  as  is  found  in  Southern 
California  or  in  New  Mexico,  should  be  recommended. 

If  bronchial  catarrh  persists  with  expectoration,  or  if  we  are  dealing 
with  an  incipient  form  of  tuberculosis,  following  this  attack  of  grip,  then 
a  change  of  air  to  Colorado,  and  out-door  life,  may  be  the  means  of  arrest- 
ing the  disease  and  effecting  a  cure. 

Alcoholic  Btimulation  must  depend  on  the  individual  case.     If  the 


INFLUENZA.  485 

infant  assimilates  milk,  broth,  cereals,  and  the  pulse  is  good,  then  alcoholic 
stimulation  is  unnecessary.  If,  however,  the  pulse  is  weak  and  very  little 
or  no  food  is  taken,  then  it  may  be  necessary  to  give  whisky,  especially  so 
if  the  pulse  is  feeble  and  the  heart  shows  signs  of  weakness.  Champagne 
may  be  given  if  persistent  vomiting,  with  exhaustion  and  heart  strain,  mani- 
fests itself. 

The  value  of  coffee  freshly  made,  to  which  some  milk  is  added,  must 
not  be  forgotten.    Caffeine  may  be  substituted  if  coffee  is  not  at  hand. 

Carbonate  of  ammonia,  in  doses  of  1  grain  for  a  child  of  1  to  2  years 
old,  repeated  every  two  or  three  hours,  will  be  useful  as  a  stimulant  during 
the  course  of  extreme  exhaustion  following  the  respiratory  type  of  this 
disease. 

To  stimulate  the  circulation  if  extreme  cyanosis  or  cold  extremities 
persist,  nothing  will  equal  judicious  massage.  Cupping  or  other  forms  of 
depletion  should  not  be  practiced  unless  severe  meningeal  symptoms  or 
constant  convulsions  demand  the  same.  Dry  cupping  over  the  chest  will  be 
found  useful  to  relieve  the  shortness  of  breath  at  the  onset  of  pneumonia. 

In  cupping  it  is  advisable  to  use  two  cups  anteriorly  and  four  cups 
posteriorly  at  the  same  time.  The  pulse  should  be  watched,  and  if  any 
irregularity  presents  itself  then  cupping  should  be  immediately  discon- 
tinued. 

The  depressing  effedts  of  the  coal-tar  products,  such  as  antipyrine  and 
phenacetine,  should  be  remembered.  If  such  drugs  are  used  they  must  be 
combined  with  camphor  or  musk  to  counteract  the  depressing  effect  on  the 
heart. 

The  fever  is  rarely  so  high  that  we  must  resort  to  antipyretic  drugs. 
I  have  seen  good  results  from  sponging  the  body  with  alcohol  and  water, 
or  with  acetic  ether,  repeated  every  hour  or  every  half-hour  if  necessary. 
If  the  temperature  persists  a  cool  pack  should  be  applied  to  the  upper 
half  of  the  body.  This  pack  should  consist  of  a  sheet  wrung  out  of  cool 
water.  The  temperature  of  the  cool  pack  is  80°  F.  These  packs  sliould 
be  repeated  every  fifteen  minutes  if  the  temperature  is  105°  F.  or  over, 
and  every  thirty  minutes  if  the  temperature  is  103°  or  104°  F.  The  same 
treatment  should  be  continued  until  the  temperature  falls  to  103°  F.  or 
lower. 

Iron  may  be  necessary  for  months  after  an  attack  of  influenza.  The 
more  simple  forms  of  iron,  such  as  neofcrrum,  are  easily  assimilated  by  a 
child.  A  preparation  that  the  writer  uses  frequently  is  tinct.  ferri.  acet. 
a-'th.,  in  doses  of  5  to  20  drops  diluted  with  water,  three  times  a  day.  This 
form  of  iron  is  easily  digested,  will  restore  tone  to  the  system,  and  increase 
the  red  blood-corpuscles  if  continued  for  some  time. 


CHAPTEE  III. 


PERTUSSIS  (WHOOPING-COUGH). 

This  acute  infectious  disease  is  caused  by  a  specific  micro-organism. 

Etiology. — The  disease  usually  gains  entrance  to  the  body  when  the 
infant  is  in  a  subnormal  condition.  We  must  therefore  expect  to  find  the 
greater  number  of  cases  in  tenement  houses,  and  in  the  crowded  districts 
of  the  poor. 

Whooping-cough  is  frequently  associated  with  measles. 

Babies  brought  up  by  hand-feeding,  so-called  bottle-babies,  suffer 
severel},  and  are  infected  more  readily  than  infants  that  are  breast-fed. 

Table  No    65. — Slatistics .-  Deaths  from   Whooping-cough  in  Children  Under 
15  Years  in  Old  City  of  New  York. 


■ 

0 
Years 

1 

Year 

2 
Yeara 

3 

Years 

4 

Years 

Under 

6 
Years 

5-10 
Years 

10-15 
Years 

1890 

Males      .    .    . 
Females      .    • 

211 
274 

115 
133 

49 
79 

33 
33 

4 
17 

6 
6 

204 
268 

7 

6 

1891 

Males 
Females      .    . 

168 

183 

95 
96 

42 

44 

16 
29 

8 
6 

4 

4 

165 
179 

3 

4 

1892 

Males      .    .    . 
Females      .    . 

156 
215 

71 
104 

51 
58 

18 
26 

9 

10 

5 
9 

154 

207 

2 
8 

1893 

Males 
Femalet 

249 

292 

122 
126 

83 
95 

25 
31 

9 
17 

5 

8 

244 

280 

5 
11 

1 

1894 

Males         .    , 
Females      .    . 

103 
169 

57 
76 

17 
45 

17 

27 

5 
9 

4 
7 

100 
164 

2 

4 

1 
1 

1895 

Males  .    . 
Females      .    . 

215 
279 

114 

127 

58 
92 

24 
30 

8 
10 

6 
10 

210 

209 

5 
10 

1896 

Males         .    . 
Females     .    . 

189 
246 

112 
113 

42 
66 

10 
34 

13 

18 

6 
5 

183 
23G 

6 

10 

1897 

Males         .    . 
Females 

132 
176 

73 

87 

26 
52 

17 
12 

13 

14 

1 
5 

130 

170 

2 
1 

1898 

Males         .    . 
Females      .    . 

198 
24;j 

105 
116 

62 

70 

18 
24 

3 

20 

7 

7 

195 
237 

3 
6 

1899 

Males      .    .    , 
Females      .    . 

158 
191 

74 
99 

58 
40 

13 
30 

11 
10 

1 
6 

157 
185 

1 
6 

1900 

Males      .    .    . 
Females  .    .    . 

143 
173 

69 

78 

38 
45 

23 
21 

3 
15 

6 
5 

139 

164 

4 
9 

1901 

Males 
Females  .    .    . 

65 
93 

31 
43 

22 
29 

7 
8 

8 

7 

1 

4 

64 
91 

1 
1 

1 

(486) 


PERTUSSIS.  487 

A  disease  whose  death-rate,  in  children  under  5  years  of  age,  ranks 
fourth,  certainly  requires  attention.  In  delicate  children  it  is  one  of  the 
most  serious  diseases  we  can  encounter. 

It  is  one  of  the  most  frequent  diseases  of  childhood  and  is  both  infec- 
tious and  contagious.     It  is  divided  into  three  stages : — 

First  Stage. — The  catarrhal  stage  in  which  the  symptoms  of  an  ordi- 
nary bronchitis  appear. 

Second  Stage. — The  paroxysmal  stage  in  which  the  characteristic  whoop 
appears. 

Tliird  Stage. — The  stage  of  decline  after  the  spasms  have  spent  their 
force. 

Bacteriology. — Behla  found  a  micro-organism  which  he  believes  be- 
longed to  the.  protozoa  group.  Similar  results  were  obtained  by  Deichler 
and  Kurloff.  In  1887  Affanasjew  found  a  bacillus  which  he  called  the 
bacillus  tussis  convulsiva.  This  germ  has  been  isolated  from  the  expectora- 
tion found  in  the  larynx  and  trachea. 

Czaplewski  and  Hensel  have  found  a  facultative  anaerobic  bacillus  re- 
sembling, morphologically,  the  influenza  bacillus,  but  somewhat  larger.  It 
has  been  impossible  to  make  a  pure  culture  of  this  so-called  specific  micro- 
organism and  reproduce  the  disease  in  animals. 

Pathology. — We  find  an  intense  congestion  in  the  lungs,  heart,  kidneys, 
and  meninges.  The  immediate  cause  of  the  paroxysms  of  whooping-cough 
must  be  attributed  to  a  nervous  origin.  It  has  been  found,  experimentally, 
that  an  irritation  of  the  superior  laryngeal  nerve  will  provoke  a  spasmodic 
cough  similar  to  whooping-cough.  ^Yhen  this  disease  exists  a  long  time 
there  is  a  profound  toxaemia,  which  is  similar  to  that  form  of  poison  so 
commonly  met  with  in  severe  infection  resembling  diphtheria. 

Symptoms. — After  an  exposure  to  whooping-cough  symptoms  may  ap- 
pear as.  early  as  three  days,  though  sometimes  not  until  one  or  two  weeks 
after  such  exposure. 

During  the  first  stage  the  diagnosis  is  at  times  very  difficult.  If  one 
or  more  cases  exist  in  the  immediate  surroundings,  and  an  exposure  to 
whooping-cough  is  brought  out  by  the  clinical  history,  then  it  is  likely  we 
are  dealing  with  whooping-cough. 

The  catarrhal  stage  lasts  about  one  week;  not  more  than  ten  days. 
Besides  tlie  symjitoms  of  bronchitis  above  mentioned,  we  have  a  history  of 
the  child  coughing  more  at  night  than  by  day,  and  less  in  the  open  air  than 
when  brought  into  the  house.  The  usual  cough  remedies  will  not  check  this 
cough.  The  child  will  not  relish  its  food.  There  is  a  craving  for  liquids, 
although  all  food  seems  to  irritate  and  excite  the  cough. 

Associated  with  this  loss  of  appetite,  there  is  usually  a  looseness  of  the 
bowels  and  diarrhoea,  which  particularly  afl'ects  the  colon  aiul  produces  a 
mucous  stool. 


488  THE  TNFECTIOrS  DISEASES. 

The  Paroxysmn]  or  WJiooping  Stayc. — Tlie  whooj)  or  paroxysm  is  usu- 
ally heard  in  the  second  or  third  week  after  the  infection  has  taken  place. 
The  paroxysm  commences  with  a  severe  cough,  followed  by  a  long  inspira- 
tion which  has  the  distinct  whoop.  The  face  assumes  a  reddish  or  cyanotic 
appearance  during  this  coughing  paroxysm.  The  coughing  spasm  usually 
ends  in  vomiting. 

When  the  paroxysms  arc  very  violent  severe  nose  bleeding  or  hiPmor- 
rhage  may  follow  a  paroxysm.  Sudden  deatli  has  followed  paroxysms,  evi- 
dently due  to  cerebral  haemorrhage. 

I  have  frequeirtly  had  the  numl)er  of  paroxysms  counted  in  twenty- 
four  hours,  and  twenty  to  fifty  are  not  unusual  in  a  severe  form  of  per- 
tussis. 

The  face  has  a  characteristic  puffy  appearance  when  the  paroxysms  are 
well  established.  The  skin  will  frequently  show  an  intense  capillary  con- 
gestion, which  can  most  frequently  be  seen  by  an  inspection  of  the  con- 
junctival mucous  meml)rane. 

Here  we  will  find  an  engorgement  of  the  S'.iialler  l)l()od-vessels  distinctly 
evident.  The  paroxysmal  stage  lasts  from  four  to  ten  weeks,  although  the 
writer  has  seen  cases  in  which  the  whoop  remained  six  months,  and  even 
longer. 

After  the  disappearance  of  the  whoop  the  catari'hal  stage  appears,  and 
convalescence  is  usually  established. 

Ulceration  of  the  Freinnii  of  the  Toiujue. — This  seems  to  l)e  directly 
due  to  the  forcible  pushing  forward  of  the  tongue  during  the  paroxysm  of 
cough.  This  stretches  the  frenum  and  brings  it  in  contact  with  the  teeth, 
causing  ulceration. 

Tlie  Stage  of  Decline. — The  symptoms  of  the  third  stage  or  stage  of 
decline  resemble  those  of  the  first  stage.  Catarrhal  symptoms  continue. 
There  is  extreme  exhaustion  from  the  paroxysms  of  cough.  It  renders  the 
child  very  livid.  Profound  ana-mia  and  heart  failure  are  most  frecpiently 
met  with  in  this  stage. 

Particular  care  must  l)e  given  to  the  restoration  of  the  normal  func- 
tions of  the  heart  and  the  respiratory  tract;  also  in  toning  up  the  stomach 
and  bowels.  Cold  extremities  are  met  with,  showing  a  poor  circulation  of 
the  blood. 

Diagnosis. — "When  the  blood  shows  a  marked  lymphocytosis  in  a  case  of 
continuous  cough  we  should  suspect  pertussis.  A  high  lymphocyte  count 
usually  means  pertussis. 

One  attack  of  whooping-cough  usually  renders  the  child  immune. 
This  is,  however,  not  always  the  case.  Cases  are  recorded  in  Mdiich  whoop- 
ing-cough has  appeared  a  second  time. 

Complications. — The  most  frequent  complication  seen  by  me  is  bron- 
cho-pneumonia.    Chronic  pulmonary  disease,  such  as  tuberculosis,  has  fre- 


PERTUSSIS.  489 

quently  followed  pertussis.  Empyema  has  been  seen  by  me  associated  with 
pertussis.  The  heart  must  be  carefully  watched  and  cardiac  stimulants 
given  when  weakness  is  noticed.  Heart-strain  from  the  paroxysms  has 
occasionally  caused  death.  Epistaxis  of  a  very  serious  nature  may  result 
from  a  violent  spasm.  Cerebral  haemorrhage  and  sudden  death  due  to 
apoplexy  has  followed  violent  paroxysms  of  cough.  Prolapse  of  the  rectum 
is  a  common  occurrence  when  the  spasms  are  prolonged.  Hernia  may  also 
result  from  severe  spasms.  I  have  seen  umbilical  and  inguinal  hernia  very 
frequently  during  the  spasmodic  stage  of  pertussis. 

The  danger  of  suffocation  must  not  be  forgotten  and  intubation  of  the 
larj^nx  (see  chapter  on  'Tntubation")  may  be  required. 

Convulsions  are  not  frequently  met  with  in  the  course  of  this  disease. 
The  writer  met  with  a  case  of  pertussis  in  which  death  resulted  from  con- 
vulsions after  a  coughing  paroxysm.  They  are  usually  fatal  when  they  do 
occur.  Paralysis  frequently  follows  severe  spasms  caused  by  intracranial 
haemorrhage.  Such  paralysis  usually  improves  under  careful  treatment, 
and  not  infrequently  do  we  find  children  completely  cured  after  a  distinct 
stroke  of  paralysis.      Strabismus  occasionally  follows  this  disease. 

Aphasia  and  loss  of  vision  are  sometimes  encountered.  These  condi- 
tions frequently  improve  when  the  system  is  strengthened  by  restorative 
treatment. 

Bloody  urine  is  frequently  met  with  in  very  young  children  during 
the  course  of  a  severe  attack  of  pertussis. 

Xephritis  is  sometimes  met  with  and  may  last  for  months  after  the 
disease  has  disappeared.  Diabetes  mellitus  has  been  reported  following  an 
attack  of  whooping-cough.  The  writer  has  scon  a  case  of  this  kind,  extend- 
ing over  two  years,  which  resulted  favorably. 

Prognosis  and  Course. — This  depends  upon  the  presence  or  absence  of 
complications.  When  laryngeal  complications  such  as  oedema  of  the 
glottis  exist,  the  prognosis  is  grave.  If  broncho-pneumonia  is  present  and 
the  heart  is  weak,  then  the  prognosis  is  doubtful.  Atelectasis  involving 
part  of  the  lobe  or  even  several  lobes  of  the  lung  is  usually  met  with  in 
rickety  children,  and  results  fatally.  When  pleurisy  complicates  whoop- 
ing-cough, a  guarded  prognosis  should  be  given.  If  an  effusion  exists  the 
same  should  be  watched  until  it  is  absorbed.  If  an  empyema  complicates 
a  case  of  violent  pertussis  the  prognosis  is  very  poor.  Emphysema  is  fre- 
quently met  with  when  there  is  severe  and  frequent  coughing.  When  this 
latter  complication  exists  recovery  is  very  slow. 

Treatment. — Prophylactic  Treatment:  When  a  case  of  whooping-cough 
occurs  in  a  house,  it  is  a  good  plan  to  give  the  other  healthy  children  from 
5  to  10  grains  of  sulpho-carbolate  of  sodium,  three  or  four  times  a  day  for 
two  weeks.  This  will  be  during  the  longest  period  of  incubation.  Exer- 
cise in  the  open  air,  walking,  etc.    Fresh  air  at  night  by  proper  ventilation, 


490  THE  INFECTIOUS  DISEASES. 

aud  dietetic  measures  may  be  the  means  of  preventing  an  attack  of  per- 
tussis. 

Owing  to  the  contagious  character  of  this  disease  we  must  insist  on  the 
strictest  isolation  of  every  child  suffering  with  whooping-cough,  until  the 
last  vestige  of  cough  has  disappeared.  The  specific  infectious  character  of 
this  disease  demands  the  strictest  attention  to  the  disinfection  of  every  bit 
of  clothing  worn  by  such  a  child.  In  addition  thereto  all  expectoration  or 
vomit  must  be  disinfected  by  the  addition  of  a  1  to  2000  solution  of  bichlo- 
ride of  mercury.  It  is  only  in  this  manner  that  we  can  destroy  the  infec- 
tious agent  which  is  known  to  transmit  this  disease.  A  child  suffering  with 
whooping-cough  must  sleep  alone,  and  if  at  all  possible,  should  have  sepa- 
rate dishes  and  utensils  during  the  whole  course  of  this  disease. 

Feeding. — Next  in  importance  to  hygienic  measures  is  feeding.  If  an 
infant  at  the  breast  has  whooping-cough,  then  it  is  a  simple  matter  to  regu- 
late its  food.  If  spasms  of  cough  are  followed  by  frequent  vomiting,  then 
the  writer  insists  on  feeding  the  nursing  infant  soon  after  the  spasm  ceased. 
When  coughing  spasms  are  provoked  to  such  an  extent  that  no  food  will  be 
retained,  and  if  there  is  a  very  feeble  pulse,  and  exhaustion  following  such 
inanition,  then,  and  then  only,  must  we  resort  to  rectal  feeding.  This  form 
of  feeding  has  been  described  elsewhere  in  this  book.  (Eead  chapter  on 
"Eectal  Feeding.") 

When  vomiting  is  very  serious,  Baginsky  recommends  menthol  in 
doses  of  Vio  or  ^/4  grain,  repeated  every  two  hours  until  the  desired  effect  is 
produced.  Frequently  the  inhalation  of  chloroform  or  ether  may  be  neces- 
sary to  check  the  paroxysms  and  relieve  vomiting. 

Hygienic  Treatment. — The  intelligent  management  of  a  case  of  whoop- 
ing-cough depends  on  the  environment  in  which  the  patient  exists.  Thus 
if  a  child  suffers  with  severe  whooping-cough  and  lives  in  a  crowded  apart- 
ment in  the  city,  it  will  be  immediately  benefited  by  a  change  to  the 
country.  Whether  such  children  be  given  mountain  air  or  removed  to  the 
seashore  is  immaterial.  The  pine-needle  air  of  the  woods  or  mountains  is 
certainly  beneficial.  The  same  is  equally  true  of  the  ozone  at  the  seashore, 
or  on  an  ocean  trip.  Thus  one  child  will  be  benefited  by  a  trip  to  Europe, 
while  another  will  receive  an  equal  benefit  by  being  sent  to  the  mountains. 
When,  however,  neither  of  these  trips  are  possible,  then  common  sense 
must  be  used. 

The  first  remedy  demanded  is  fresh  air.  It  is  advisable  to  insist  on 
having  the  windows  open  both  night  and  day  if  the  child  is  indoors,  and 
to  instruct  the  mother  or  nurse  regarding  the  necessity  of  fresh  night  air 
as  well  as  fresh  day  air. 

There  seems  to  be  a  predilection  regarding  the  danger  lurking  in  night 
air,  and  children  are  crowded  into  stuffy  apartments  and  permitted  to- 
breathe  vitiated  air  at  night  rather  than  open  the  windows.     This  is  the 


PERTUSSia  491 

real  cause  of  such  children  coughing  more  at  night  than  during  the  day. 
The  administration  of  oxygen  and  also  of  ozone  has  its  advocates.  All 
noxious  odors  and  all  irritants,  such  as  tobacco  smoke  or  kitchen  vapors, 
must  be  guarded  against;  in  other  Avords,  the  air  should  be  kept  as  pure 
as  possible. 

Medicinal  Treatment. — We  have  no  specific  in  tJiR  treatment  of  this 
disease.  For  the  treatment  of  whooping-cough  hundreds  of  remedies  have 
been  suggested.  Some  of  the  older  remedies,  such  as  belladonna, 
hyoscyamus,  codeine,  and  morphine,  have  their  advocates. 

There  is  no  question  in  my  mind  about  the  efficacy  of  some  of  the 
remedies  just  mentioned.  In  spite  of  the  value  of  those  drugs,  a  great 
many  cases  will  show  no  benefit  after  their  use. 

Every  podiatrist  is  guided  by  his  individual  experience,  and  thus  it  is 
that  one  remedy  will  do  good  in  a  certain  class  of  cases  and  disappoint  in 
another. 

Bromoform*  was  introduced  in  this  country  by  the  author. 

In  a  series  of  51  cases  published  at  that  time,  marked  improvement  was 
the  rule  in  most  cases,  although  there  were  several  instances  in  which  no 
appreciable  benefit  was  observed. 

The  dose  of  bromof orm  is  from  2  to  5  drops  three  times  a  day,  for  a 
child  1  year  old.  It  is  wise  to  begin  with  a  minimum  dose  and  gradually 
increase  the  same  to  the  point  of  toleration.  We  commence  with  a  2-drop 
dose,  give  it  three  times  a  day,  then  increase  1  drop  more  each  day  until 
a  decided  amelioration  of  the  paroxysms  is  noticed.  My  plan  has  been  the 
following:  To  instruct  the  mother  or  nurse  to  count  the  number  of  parox- 
ysms that  the  child  has  in  twenty-four  hours. 

IJ  Br omoform 1       drachm 

Spir.  vini  albi 2  "/a  drachms 

Syr.  tolu 1       ounce 

Mucilag.  acacia q.  s.  ad  2       ounces 

M.     From  Va  to  1  teaspoonful  every  four  hours. 

Owing  to  the  extreme  volatility  of  this  drug,  great  care  must  be  exer- 
cised in  its  administration,  and  it  is  a  good  plan  to  keep  the  same  in  a  well- 
stoppered  bottle  and  also  in  a  cool  place. 

The  increase  of  the  dose  of  bromoform  depends  on  the  point  of  toler- 
ance. Thus,  if  the  child  appears  very  drowsy  and  sleepy  and  shows  signs 
of  intoxication  after  a  3  or  a  4-drop  dose,  then  it  is  a  good  plan  to  combine 
a  small  dose  of  caffeine  citrate  with  it,  or  if  the  child  is  old  enough,  give  it 
a  few  drops  of  strong  coffee  after  the  dose  of  bromoform  has  been  given. 


'  The  article  appeared  in  extenso  in  the  New  York  Medical  Record  for  September 
6,  1890. 


492  THE  r^FECTnOUS  DISEASES. 

The  writer  has  frequently  given  7,  8,  9,  or  10  drops  of  pure  hromoform  in 
one  close  to  an  infant  1  year  old,  by  gradually  increasing  the  dose  from  two 
drops  in  the  manner  above  described. 

Bromoform  acts  similarly  to  chloroform  and  it  is  advisable  to  use 
extreme  care  with  children  who  might  be  very  susceptible  to  ordinary  drug 
treatment.  Children  suffering  with  profound  ana3m'a  or  rachitic  children, 
or  children  having  tuberculosis,  or  those  suffering  with  syphilis,  should  bo 
carefully  watched. 

Toxic  effects  have  been  reported  both  in  this  country^  and  abroad. 

Aniipi/rine,  in  doses  of  1  to  5  grains  three  times  a  day,  acts  quite  well 
in  some  cases.     It  is  well  worth  trying,  especially  in  very  nervous  children. 

Tussol. — Tussol  is  a  derivative  of  antipyrine  and  has  been  advocated 
by  Rehn-  and  later  by  Eothschild,'  and  in  an  elaborate  paper  by  Dr. 
Urban,  from  the  Children's  Hospital  of  Vienna. 

The  writer  has  had  some  experience  with  tussol  and  has  found  instances 
in  which  the  paroxysms  were  modified  just  as  they  were  when  phenocoll  or 
antipyrine  was  used.  The  method  of  administering  it  was  to  suspend  it 
either  in  syrup  of  orange  or  raspberry  syrup,  in  doses  varying  from  2  to  5 
grains  for  a  child  1  year  old,  older  children,  larger  doses  in  proportion. 

What  has  been  said  regarding  the  depressing  effect  on  the  heart  by  the 
antipyretic  group  applies  equally  strong  to  this  latter  day  drug.  When 
large  doses  are  given,  then  some  cardiac  stimulant  should  be  combined  with 
it  to  offset  the  depressing  action  on  the  heart. 

Fischal*  gives  a  clinical  report  regarding  the  newer  remedies  suggested 
in  the  treatment  of  whooping-cough,  as  lactophenin  and  euchinin.  These 
belong  to  the  antipyretic  group.  Other  substances  have  been  recommended 
in  this  disease.  Among  the  newer  remedies  suggested  are  pasterin,  anti- 
tussin,  pertussin,  antispasmin. 

Antitussin. — A  conscientious  trial  of  this  drug  in  the  children's  service 
of  the  writer,  slowed  no  benefit  whatever  after  its  use.  Hein  advocates  the 
use  of  antitussin.^ 

Fischal  has  seen  the  paroxysmal  curve  of  21  daily,  drop  to  7  daily, 
immediately  after  using  antitussin.    Several  days  sufhced  to  complete  a  cure. 

Phenocollum  hydrochloricum  has  been  before  the  profession  for  a 
number  of  years;  Martinez  Vargas,  in  Barcelona,  advocates  the  use  of  this 
drug,  after  giving  detailed  clinical  histories  in  an  extensive  article." 


I 


*  "Bromoform   Poisoning,   Recovery   in    a    Child,"    published    in    delail    in    tlie 
Annals  of  Gyna;eology  and  Pediatrj',  1897  (Fischer). 

''  Munch.  Med.  Wochen.,  1894,  No.  46. 
•Berlin.  Klin.  Wochen.,  1896,  No.  1. 
*Med.  Chir.  Centralblatt,  June  29,  1900. 
"Berlin.  Klin.  Wochen.,  No.  50,  1899. 

•  Therapeutischcn  Wochenschrift,  January  5,  1890. 


PERTUSSIS.  493 

We  found  beneficial  results  in  a  series  of  cases  in  which  a  great  many 
other  drugs  had  been  previously  used.  A  child  one  month  old  received 
about  10  grains  of  phenocoll  in  the  course  of  twenty-four  hours. 

The  action  of  phenocoll  is  reported  to  be  very  quick.  It  passes  through 
the  system  and  is  excreted  in  about  twenty  minutes. 

Robert  and  Mering  found  that  phenocoll  does  not  alter  the  character 
of  the  blood.  It  reduces  the  temperature,  diminishes  the  quantity  of  urea 
and  of  nitrogen,  and  also  the  total  solids  in  the  urine.  It  seems  to  exert 
its  influence  on  the  nervous  system,  causing  a  decrease  in  the  convulsive 
character  of  the  cough. 

The  slightly  bitter  taste  of  this  drug  can  be  masked  by  adding  a  little 
syrup.  It  acts  not  only  on  the  nerve  centers,  on  the  cerebellum  and  spinal 
cord,  but  also  on  their  peripheral  ramifications,  producing  a  slight  warmth 
in  the  head  and  flushing  the  face.  It  determines  varying  degrees  of  dilata- 
tion of  the  pupil,  especially  when  administered  in  large  doses;  thus' 
mydriasis  persists  even  after  all  other  characteristic  symptoms  of  pheno- 
coll have  disappeared. 

The  dose  is  from  5  grains,  for  a  child  1  year  old,  gradually  increased 
to  8  grains,  administered  in  water  or  syrup  three  times  a  day  until  the  effect 
is  marked. 

Phenocoll  has  also  been  advocated  by  Vergas  and  Grigorieff,  and  by 
Polievkstoff  in  Petersburg.  The  writer  has  had  some  experience  with 
phenocoll,  and  has  found  that  very  mild  cases  seem  to  respond  to  its  admin- 
istration in  the  same  manner  as  antipyrine  has  given  results.  Specific  action 
and  immediate  relief  in  severe  paroxysmal  attacks  was  not  noted. 

Antispasmodi-cs. — When  the  paroxysms  of  whooping-cough  are  very 
severe,  especially  at  night,  causing  insomnia,  it  is  very  vital  to  give  the 
child  some  sleep.  The  antispasmodics,  like  belladonna,  require  either  the 
addition  of  bromide  of  sodium  or  bromide  of  potassium.  A  5-grain  dose 
of  bromide  of  sodium,  administered  shortly  before  putting  the  child  to 
bed,  will  frequently  allay  irritation  and  give  refreshing  sleep.  The  do^e 
may  be  doubled  and  10  grains  of  bromide  of  sodium  given  to  a  child  1  year 
old,  if  a  o-grain  dose  has  had  no  effect.  Frequently  from  1  to  2  grains  of 
chloral  hydrate  added  to  a  5-grain  dose  of  bromide  of  sodium  will  act  more 
beneficially. 

When  drugs  are  not  well  borne  by  the  mouth  and  the  slightest  amount 
of  liquid  swallowed  will  cause  an  irritation  and  provoke  a  parox3'sra  of 
cough,  then  it  is  advisable  to  feed  the  child  per  rectum.  We  can  also  ad- 
minister the  drugs  in  the  form  of  suppositories  per  rectum.  It  is  a  good 
plan  to  increase  the  dose  per  rectum;  thus  if  a  child  receive  5  grains  per 
mouth,  thon  10  grains  should  be  given  for  a  corresponding  dose  per  rectum. 

Regarding  Antitoxin. — Whooping-cough  is  a  self-limitod  disease,  and 
one  single  attack  is  usually  protective  against  subsequent  infection.     Thus 


494  THE  INFECTIOUS  DISEASES. 

it  appears  that  some  antitoxin  may  possibly  be  generated  during  convales- 
cence. 

As  soon  as  a  specific  micro-organism  can  be  cultivated  and  the  diseiii^e 
reproduced  in  lower  animals,  just  as  we  can  to-day  isolate  the  specific 
micro-organism  causing  diphtheria,  then  we  may  hope  for  an  antitoxin. 

Vaccination  of  the  arm  with  bovine  virus  has  been  advocated  by  some 
in  the  treatment  of  whooping-cough.  The  writer  has  never  seen  any  benefic 
from  its  use.    It  can  do  no  harm  if  a  child  has  never  been  vaccinated. 

Anti-pneumococcic  serum  has  been  advocated  by  many  for  the  treat- 
ment of  whooping-cough.  Why  it  should  be  used  I  fail  to  understand  and 
cannot  conscientiously  recommend  the  use  of  the  same  in  this  disease. 

Creosote  or  creosote  carbonate  has  been  advocated  by  some  in  the  treat- 
ment of  the  paroxysmal  cough.  It  has  served  the  writer  very  well  in  con- 
junction with  codliver-oil  and  malt  as  a  restorative,  after  the  paroxysms 
had  spent  their  force,  but  no  specific  action  could  be  ascribed  to  the  use  of 
creosote  carbonate  alone  or  in  combination. 

When  whooping-cough  existed  in  a  tubercular  child,  then  marked 
benefit  was  noted  by  the  administration  of  2  to  5  drops  of  creosote  carbonate 
three  times  a  day,  given  in  milk,  soup,  or  broth,  and  the  dose  gradually 
increased  until  12  drops,  three  times  a  day,  was  administered.  The  benefit 
derived  in  these  cases  must  be  attributed  to  the  action  of  creosote  for  the 
tuberculosis,  rather  than  its  specific  action  in  whooping-cough. 

Steam  Inhalations. — Medicated  steam  is  frequently  useful,  more  espe- 
cially when  the  cough  is  violent.  When  pertussis  is  complicated  by  bron- 
chitis steam  vapor  should  be  used  every  five  or  six  hours.  A  teaspoonful  of 
beechwood  creosote  added  to  a  pint  of  steaming  water  and  placed  several 
feet  from  the  child's  bed,  will  impregnate  the  air  in  the  room. 

Heroin  has  been  extolled  by  many  as  a  useful  adjuvant  in  the  treat- 
ment of  catarrhal  affections.  The  following  case  is  interesting  to  show  the 
dangers  of  idiosyncrasies  in  some  children : — 

An  infant,  eleven  months  old,  very  rachitic,  poorly  nourished,  was  exposed  to 
whooping-cough  in  a  large  apartment  house.  The  paroxysms  were  violent  and 
fre<juently  ended  with  vomiting.  The  child  was  greatly  exhausted  from  cough  and 
weakened  from  inanition.  Expectorants  and  antispasmodics  excited  little  or  no 
influence  over  the  cough. 

Heroin,  Veo  grain,  was  prescribed  three  times  a  day  for  three  days.  This 
produced  a  distinct  stupor.  Such  was  the  condition  noted  by  me  when  I  saw  the  case 
in  consultation  with  Dr.  John  H.  Wurthman.  There  was  no  rigidity  of  the  sterno- 
cleido  mastoid  nor  was  opisthotonos  present.  The  patellar  reflexes  were  present. 
The  symptoms  subsided  when  the  drug  was  discontinued  and  cardiac  stimulants  were 
prescribed.  The  symptoms  were  undoubtedly  due  to  heroin  poisoning.  It  is  possible 
that  we  were  dealing  with  a  drug  idiosyncrasy  as  the  toxic  symptoms  passed  away  in 
about  twenty-four  hours. 

Dionin  in  pertussis  has  been  recommended  by  Von  Mering  in  the  fol- 
lowing doses: — 


PERTUSSIS.  495 

For  a  child  1  year  old: — 

B  Dionin    (Merck) */•  grain 

Aqua  3  ounces 

Sig.:      One  drachm  every  three  hours. 

For  a  child  2  years  old : — 

IJ  Dionin  V.  grain 

Aqua   3  ounces 

Sig.:      One  draxrhm  every  three  hours. 

For  a  child  3  years  old : — 

IJ  Dionin V,  grain 

Aqua  3  ounces 

Sig.:      One  drachm  every  three  hours. 

Pertussin^  has  been  used  by  me  for  several  years  with  remarkably  good 
results.  I  have  given  a  teaspoonful  three  and  four  times  a  day.  To  older 
children  2  teaspoonfuls  three  and  four  times  a  day,  also  at  night  until  the 
paroxysms  were  modified. 

■Restorative  Treatment. — Malt  extract  with  hypophosphites  and  cod- 
liver-oil,  sweet  cream,  milk,  eggs,  and  butter  form  the  most  valuable  part 
of  the  treatment. 

Produce  Sleep  at  Night. — Next  to  exhaustion  from  violent  paroxysms 
of  cough,  heart  strain,  and  loss  of  food  from  vomiting,  is  loss  of  sleep. 
Sleep  should  be  produced  to  aid  in  restoring  normal  conditions.  Trional  in 
1  to  5-grain  doses,  repeated  in  two  hours,  is  very  useful  in  some  cases.  I 
have  previously  mentioned  the  good  effects  of  bromides  as  antispasmodics. 
Paregoric  in  10  to  20-drop  doses,  according  to  the  age  and  requirement  of 
the  case,  will  be  found  useful  in  some  cases.  A  large  dose  (tablespoonful)  of 
castor-oil  will  frequently  exert  a  very  soothing  effect  on  the  inflamed  and 
sensitive  mucous  membrane. 

Spray. — A  3  per  cent,  cocaine  spray  in  the  throat,  used  several  times  a 
day,  or  a  3  per  cent,  eucaine  spray  will  frequently  give  local  relief  if  severe 
paroxysms  are  followed  by  vomiting.  The  writer  has  frequently  given  the 
latter  spray  in  conjunction  with  one  of  the  above-mentioned  drugs. 

Ethyl  chloride  has  been  used  as  a  spray  during  violent  spasms.  It 
produces  anaesthesia,  thus  affording  temporary  relief.  An  oil  spray,  con- 
sisting of  albolin  or  liquid  vaseline  used  with  an  oil  atomizer,  lubricates 
the  mucous  membrane  and  sometimes  affords  relief. 

The  Naso-pharynx. — Ptcflex  irritations  such  as  nasal  catarrh  and  ade- 
noids frequently  excite  paroxysms  of  cough,  hence  they  should  be  removed 
by  operation  if  present. 

^  Sold  in  drug  stores.    Made  by  Tacschner. 


496  THE  INFECTIOUS  DISEASES. 

A  mild  antiseptic  irrigation  of  the  naso-pharynx  will  be  found  advan- 
tageous. 

For  this  purpose  use: — 

IJ  DobcU's    sol 1  part 

Aqua    3  parts 

The  above  can  also  be  used  in  the  form  of  a  steam  spray  directed 
against  the  pharynx. 

Seller's  tablets  are  also  valuable.  One  tablet  dissolved  in  a  teacup  of 
lukewarm  water,  or: — 

Mechanical  Treatment. — The  value  of  an  abdominal  binder  as  a  sup- 
port in  the  treatment  of  whooping-cough  is  emphasized  by  Kilmer.^ 

My  personal  experience  has  been  quite  good  with  this  form  of  support. 
It  probably  gives  the  same  mechanical  relief  as  does  the  strapping  in  pleu- 
risy. 


1 


*  Section  on  Pediatrics,  American  Medical  Association,  1904. 


CHAPTER  IV. 

PNEUMONIA  (LOBAR  OR  CROUPOUS). 

This  acute  infectious  disease  is  frequently  seen  in  infancy  and  child- 
hood. It  is  caused  by  the  invasion  of  a  specific  micro-organism,  the  pneu- 
mococcus,  also  known  as  the  micrococcus  lanceolatus.  The  disease  rarely 
exists  longer  than  from  six  to  nine  days.  It  terminates  by  crisis.  It  is  a 
self-limited  disease.    In  some  cases  it  may  terminate  by  lysis. 

Etiology. — This  disease  most  frequently  exists  in  children  between  the 
ages  of  5  and  10  years.  Baginsky  states  that  among  173  pneumonias 
studied  by  him,  he  found  the  following: — 

6  children  less  than  1  year  old. 
28  children  between     1  and     2  years. 
58  children  between     2  and     5  years. 
63  children  between     5  and  10  years. 
18  children  between  10  and  14  years. 

We  find  on  studying  the  above  cases  that  the  greatest  number  of  pneu- 
monias are  found  in  children  between  the  ages  of  5  and  10  years.  Schles- 
inger  studied  a  series  of  cases  of  pneumonia  and  found  that  96  cases  affected 
the  right  lung  as  against  66  cases  affecting  the  left  lung.  He  also  found  on 
the  right  side  of  the  lung:— 

22  cases  affecting  the  upper  lobe. 
7  cases  affecting  the  middle  lobe. 
32  cases  affecting  the  lower  lobe. 

On  the  left  side  of  the  lung : — 

11  cases  affecting  the  upper  lobe. 
00  cases  affecting  the  middle  lobe. 
47  cases  affecting  the  lower  lobe. 

Thus  he  found  that  the  lower  lobes  on  both  sides  of  the  lungs  were 
more  frequently  affected  than  the  upper  lobes,  and  that  the  seat  of  pneu- 
monia in  children  corresponded  with  the  investigations  of  Von  Dusch, 
showing  that  the  most  frequent  seat  of  pneumonia  of  the  lobar  variety  is 
certainly  found  at  the  base  of  the  lower  lobe  of  the  left  lung.  This  is  an 
important  diagnostic  point  when  symptoms  point  to  the  development  of 
pneumonia. 

Bacteriology. — The  disease  originates  by  an  invasion  of  a  specific  raicro- 
organlBm  first  described  by  A.  Fraenkel.  Other  investigators,  among 
them  Klebs,  Ziehl,  and  C.  Friedlander,  have  found  various  micro-organisms 
in  the  lymph  channels,  and  in  the  alveoli  of  pneumonic  lungs.     Some  of 

(497) 


498 


THE  INFECTIOUS  DISEASES. 


these  germs  have  been  encapsulated.  It  remained,  however,  for  Fraenkel  to 
find  the  specific  germ  causing  this  disease.  Weichselbaum  was  one  of  the 
first  to  prove  the  positive  specific  infection  of  the  Fraenkel  diplococcus. 


f 


HI 


Fig.  151. — Focal  Metastatic  Hematogenous  Streptococcus  Pneumonia 
Following  Angina,  (a)  Pneumonic  focus  with  streptococci  (blue)  inflamed 
surrounding  tissue.     X  80.      (Ziegler.) 


Fig.  1.52. — Croupous  Pneumonia.  Red  hepatization  of  the  lung  (alco- 
hol, carmine,  fibrin-stain),  (a)  Infiltrated  alveolar  septa;  (6)  fibrinous 
exudate;    (c)   red  blood-cells.     X  200.      (Ziegler.) 


.  WANDERING  PXEl  MOXIA.  499 

This  diplococcus  is  found  not  only  in  the  lungs,  but  frequently  also  in  the 
meninges,  in  the  nasal  secretions  from  the  nasal  mucous  membrane,  and  at 
times  in  the  kidneys.  Wherever  this  micro-organism  is  found  there  is 
usually  an  inflammatory  condition  resulting  therefrom. 

When  this  specific  germ  was  injected  into  animals,  pneumonia  always 
resulted. 

Pathology. — There  are  four  stages  which  have  an  important  bearing 
on  the  progress  and  on  the  outcome  of  this  disease.  First,  the  stage  of 
congestion;  second,  the  stage  of  red  hepatization;  third,  the  stage  of  gray 
hepatization,  and  fourth,  the  stage  of  defervescence  or  resolution. 

Varieties  of  Pneumonia. 

Abortive  Pneumonia. — This  form  of  pneumonia  is  frequently  disbe- 
lieved by  some  clinical  observers.  At  times  children  who  are  in  apparent 
good  health  will  suddenly  have  intense  fever,  cough,  and  on  physical  ex- 
amination show  distinct  symptoms  of  pneumonia.  Frequently  dullness  on 
percussion  in  addition  to  bronchial  breathing  will  be  plainly  made  out.  In 
two,  possibly  three  days,  the  whole  clinical  picture  will  be  changed  and  the 
child  will  appear  to  be  normal.  This  form  of  pneumonia  has  been  recog- 
nized and  studied  by  other  authors,  but  Baginsky  maintains  that  the  dis- 
ease is  of  the  abortive  type.  It  is  quite  possible  that  some  of  these  symptoms 
have  been  latent  for  several  days  prior  to  the  detection  of  the  physical  signs, 
and  thus  what  appears  to  be  an  abortive  form  of  pneumonia  covering  two 
or  three  days  may  easily  have  existed  for  several  days  prior  to  the  detection 
of  the  same. 

Pneumonia  Gastrica. — This  form  of  the  disease  is  one  in  which  the 
symptoms  of  vomiting  and  diarrhoea  predominate,  and  hence  it  is  known 
as  the  gastric  type  of  pneumonia.  While  the  lungs  will  show  the  usual 
symptoms  of  a  croupous  pneumonia,  the  tongue,  stomach,  and  bowels  will 
present  symptoms  of  an  intense  inflammatory  condition  of  the  digestive 
tract.    Not  infrequently  jaundice  may  be  present. 

The  conjunctival  mucous  membrane  may  be  pigmented  from  the  pres- 
ence of  bile.  The  secretions  may  also  show  biliary  pigmentation.  Herpes 
may  appear  on  the  upper  lip,  thus  showing  that  there  is  an  intense  inflam- 
matory condition  affecting  primarily  the  digestive  tract. 

Wandering  Pneumonia  ("Pneumonia  Migrans"). — This  form  of  pneu- 
monia is  met  with  quite  frequently.  The  symptoms  are  those  common  to 
lobar  pneumonia,  as  chills,  fever,  and  the  usual  physical  symptoms  of  a 
consolidated  lung  in  this  condition.  The  name  is  derived  from  its  tendency 
to  spread  from  lobe  to  lobe.  The  infection  usually  commences  in  one  lobe 
and  spreads  to  the  second,  to  the  third,  and  frequently  when  the  crisis 
has  taken  place  the  disease  commences  with  full  force  in  another  lobe  and 
may  continue  so  for  several  weeks.     That  this  form  of  pneumonia  is  very 


500 


THE  INFECTIOUS  DISEASES. 


Tig.  153. — Case  of  TnfliipTiza  and  Pneumonia.  The  disease  spread  from 
lobe  to  lobe  so  that  the  child  passed  through  several  distinct  inflammations. 
This  form  is  known  as  Pneumonia  Migrans  (Wandering  Type)  Careful 
dieting  aided  by  stimulation,  and  the  fever  treated  by  cold  compresses  and 
cold  colon  llushings  aided  recovery.     (Original.) 


PLEURO-PNEUMON  lA. 


r)01 


serious  can  he  easily  imagined.  A  child  having  suffered  with  acute  lobar 
pneumonia  and  passed  its  crisis  Avith  an  already  weakened  heart,  and  has 
again  to  pass  through  the  second  pneumonia  and  frequently  through  a  third 
and  a  fourth,  must  certainly  have  great  vitality  in  order  ta  recover  from 
the  depression  caused  thereby. 

The  depressing  effect  on  the  heart  from  a  continued  fever  in  addition 
to  the  toxcpmia  must  be  taken  into  account  in  giving  the  prognosis ;  hence 
it  is  safe  to  assume  that  the  prognosis  in  every  pneumonia  migrans  is  neces- 
sarily grave.  Stimulation,  which  is  so  urgently  called  for  in.  the  usual  form 
of  lobar  pneumonia,  is  imperative  in  this  variety  of  the  disease. 

Pleuro-pneumonia. — It  is  rare 
to  find  lobar  pneumonia  without  an 
associated  in'flammation  of  the  pul- 
monary pleura.  Xot  infrequently 
with  a  severe  type  of  broncho-pneu- 
monia covering  large  areas  of  con- 
solidation there  is  a  co-existing  in- 
flammation oi  the  pleura.  It  is 
difficult  to  state  at  times  which  lesion 
began  first,  Avhether  it  was  the  pleu- 
risy or  the  pneumonia,  in  a  given 
case  of  pleuro-pneumonia. 

Pathology  and  Bacteriology. — 
The  infection  is  usually  caused  l)y 
the  pneujnococcus.  In  pleuro-pneu- 
monia both  the  visceral  and  the  parietal  pleura  are  coated  with  a  large  layer 
of  yellowish-green  fibrin,  in  thick,  shaggy  masses,  by  which  the  lung  is 
adherent  to  the  chest-wall,  the  diaphragm,  and  the  pericardium.  The 
exudation  varies  between  one-eighth  and  one-half  inch  in  thickness.  It  can 
often  be  stripped  from  the  lung  or  scraped  from  the  chest-wall  by  the  hand- 
ful. In  its  meshes  small  pockets  may  form  which  contain  only  a  few  drops, 
or  sometimes  a  drachm  of  pus,  or,  less  frequently,  serum.  This  is  the  con- 
dition in  which  the  lung  is  usually  found  when  death  has  occurred  at  the 
height  of  the  disease.  If  the  process  has  lasted  longer,  larger  collections  of 
pus  may  be  present.  The  lung  itself  shows  the  usual  changes  of  pneumonia, 
and  if  there  has  been  any  considerable  accumulation  of  fluid,  there  are  in 
addition  the  evidences  of  compression. 

AVith  pleuro-jmeumonia  of  the  left  side,  the  pericardium  is  occasionally 
involved.  This  was  seen  in  two  of  my  cases,  the  lesions  closely  resembling 
those  of  the  pleura.  In  two  cases  there  was  also  meningitis,  and  in  one 
peritonitis,  the  exudation  in  all  cases  having  the  same  characteristics  (Holt). 

Symptoms. — The  fi-iction  sound  is  tlu'  characteristic  feature  througliout. 
In  addition  to  the  })leuritic   friction  sounds,  the  symptoms  of  pneumonia. 


Day      1 

1       Z       4       5       t       7 

Fahr.  M    Z 

,.    ..     -                   , — 1 

lO^ 

m 

3   -ji-   -^ 

7"' 

"^^0  a  -A 

103            ^ 

7    V^u^    t± 

~    A  V   ,  frA 

102 

\t^^  -f 

^  l^t 

101  — 1 — 

5 

v 

JOO 

-        .   , -.     -      _a 

Fig.  154. — Fever  Curve  in  Pleuro- 
pneumonia.    (Original.) 


502  THE  INFECTIOUS  DISEASES. 

such  as  bronchial  hreathin^-  and  lironcliophony,  are  found.  There  is  marked 
dullness  and  frequently  flatness  on  percussion.  This  condition  is  sometimes 
misleading.  Xot  infrequently  the  signs  of  distant  breathing  and  flatness 
on  j^ercussion,  in  addition  to  a  continuous  high  temperature  will  simulate  an 
empj'ema.  An  exploratory  needle  introduced  may  strike  a  snuill  pocket  of 
pus  and  thus  an  empyema  may  be  suspected.  These  cases,  if  operated,  fre- 
quently show  nothing  but  the  ordinary  signs  of  adhesions  so  common  at  thi> 
stage  of  the  disease. 

Prognosis. — The  prognosis  depends  on  the  severity  of  the  disease.  The 
prognosis  is  always  worse  than  in  pneumonia,  because  of  an  extent  of  the 
inflammatory  process  and  because  many  of  these  cases  terminate  in  tuber- 
culosis.    Cases  terminating  in  empyema,  if  operated,  get  well. 

Treatment. — The  treatment  of  a  pleuro-pneumonia  is  identical  with 
that  of  an  ordinary  pneumonia.  The  fever  treatment  consists  in  packing 
the  thorax.  Cough  and  pain  require  codeine  or  Dover's  powder.  If  the 
pain  is  very  severe,  stra])ping  the  chest  with  strips  of  adhesive  plaster  will 
support  the  ribs  and  relieve  the  strain  of  the  cough.  Fresh  air,  milk,  yolk 
of  egg,  soups,  for  thirst:  orange  juice,  weak  tea,  and  water,  liljerally,  arc 
required.  Attention  to  the  bowels  and  kidneys  is  an  important  factor  in 
this  disease. 

Cerebral  Pneumonia. — This  type  of  the  disease  is  one  which  is  very 
frequently  met  with  in  which  the  symptoms  of  pneumonia  are  chiefly  com- 
plicated by  meningeal  symptoms ;  thus  clonic  spasms  or  convulsions  are 
usually  present.  In.  addition,  thereto  there  is  vomiting,  constipation,  head- 
ache, opisthotonos,  delirium,  stupor,  irregularity  of  the  pulse,  and,  later 
on  in  the  disease,  coma.     In  some  cases  paralysis  is  liable  to  occur. 

Two  iNSTRrcTiVE  Cases  of  Cerebral  Pxeumoxia-I 
Case  I. — Baby  E..  about  si.x  months  old,  a  nursing  baby,  was  seen  by  me  in 
January,  1902.  in  consultation  with  Dr.  Osias.  The  history  was  as  follows:  The 
child  had  been  ill  for  several  days,  was  restless  and  feverish,  and  had  vomited.  Tlie 
stools  were  greenish  and  contained  a  large  quantity  of  chee.sy  curds,  in  addition  to 
mucus.  The  abdomen  was  slightly  retracted,  the  extremities  were  cold;  there  was 
Tio  oedema  present.  The  child  did  not  seem  to  take  the  breast  very  well  and 
vomited  frequently  after  nursing.  Tlie  temperature  was  102  Vs"  F.,  per  rectum, 
pulse  140,  respiration  44.  Unilateral  spasms  with  twitcliings  of  the  muscles  of  the 
shoulder,  arm,  leg,  and  foot  were  constantly  present.  Twitcliings  of  the  muscles 
of  the  eye  and  a  constant  rolling  of  the  eyeball  were  noticed;  the  head  was  thrown 
backward;  the  muscles  of  the  neck  Avere  ratlier  rigid,  although  there  was  no  distinct 
opistliotonos.  The  spasms  were  confined  to  the  right  side  of  the  1x)dy;  the  knee- 
jerk  at  the  patella  was  absent  on  the  right  side;  the  plantar  reflex  on  the  right  side 
was  slightly  present;  the  patellar  reflex  was  normal  on  the  left  side  and  the  plantar 
reflex  was  more  distinct;  the  pupils  responded  very  sluggishly  and  were  unusually 
large;  this  dilatation  of  the  pupils  persisted  through  the  whole  illness,  until  con- 
valescence was  established.  The  examination  of  tlie  thorax  showed  intense  pul- 
1  Reprinted  from  Archives  of  Pediatrics,  February,  1903. 


1 


CEREBRAL  PNELMOXIA. 


503 


Oionarv  congestion;  there  was  slight  resistance  on  percussion  and  marked  dullness. 
Judging  from  the  ratio  between  the  pulse  and  the  respiration,  the  diagnosis  of 
pneumonia  was  hardly  possible.  Tlie  physical  signs  on  ausculation  showed  bronchial 
breathing  and  a  distinct  crepitant  rale.  The  diagnosis  of  cerebral  pneumonia  was 
made,  although  meningitis  per  se  was  excluded. 

The  treatment  was  directed  to  relieve  the  pneumonic  infection.  Expectorants, 
in  addition  to  inhalations  of  steam,  were  ordered.  Cold  compresses  Avere  used 
as  antipyretics,  and  castor-oil  or  calomel  was  given  to  cleanse  the  gasti-o-intestiual 
tract.     The'  disease   progressed;     the   temperature   increased  and  rose  to    10-3  Vo"   F. 


Fig.  l.>.). — A  Case  of  Cerebral  Pneumonia.     (Original.) 

on  tlie  following  day,  and  to  104  -/-^°  F.  on  the  third  and  fourth  days.  With  the 
rise  of  temperature  the  pulse-rate  was  increased  to  140°,  respirations  to  52.  On 
the  fifth  day  of  the  disease  there  was  a  marked  somnolence,  stupor  and  partial 
coma.  The  head  now  showed  a  distinct  opisthotonos;  the  sti-rno-cleido  mastoids 
were  very  rigid:  the  pupils  were  botli  dilated  ami  tlie  idnviilsjons  continued  as 
before.  Leeches  were  applied  over  the  mastoid  portion  of  the  temporal  bone  to 
relieve  the  cerebral  congestion;  the  scalp  was  shaved  and  iodoform  collodion. 
10  per  cent.,  was  painted  on  the  occiput;  ice-bags  Avere  applied  over  the  whole  of 
the  cranium  as  well  as  to  the  nape  of  the  neck,  mustard  foot-baths  Avere  frequently 
given  and  afTorded  some  relief  during  the  severe  spasms.  An  enema  consisting  of 
chloral  hydrate  and  sodium  bromide,  5  grains  each,  with  1  omice  of  starch  water, 
Avas  ordered.  This  Avas  to  be  repeated  CA-ery  three  hours  until  the  spasms  ceased. 
Before  injecting  the  above  drugs  both  the  rectum  and  llic  colon  were  (lushed  with 
soap-water  enema. 

On  tlie  seventh  day  of  the  disease  there  Avas  a  distinct  crisis,  inasmuch  ns  the 


504 


THE  INFECTIOUS  DISEASES. 


ti'inpi'iaturo  dropped  from  104°  to  97°.  a  drop  of  7  degrees.      ( Fiy.   ]'-)A.)      Stimula- 
ting ex])eetorants  were  then  ordered  in  the  following  manner:  — 

R   Amnion,  carb 15  o-i-ains 

Syrup,  pruni  virgin   4  drachms 

Aqua;  camph q.  s.  ad     2  ounces 

'SI.     Half  a  teaspoonful  vvcry  two  hours. 

The  child's  convalescence  continued.  The  piu'umonia  completely  subsided;  reso- 
lution set  in;  the  sjiasms,  wliich  had  been  so  disagreeable  and  persistent,  also  stopped. 
The  child  commenced  to  show  signs  of  consciousness,  played,  laughed,  and  cooed;  the 
stools,  which  had  been   so  greenish   and   curded,  assumed   a   more  natural   vellowish 


Fig.    15G. — Cerebral   Pneumonia    with    High    Temperature    and    Marked 
Decrease  in  Temperature  After  Cold  Baths.      (Original.) 

color  and  pasty  consistency.  The  appetite  seemed  to  return;  the  infant  nursed 
better,  the  nights  were  more  comfortable,  and  the  child  slept  from  one  feeding  time 
until  the  next. 

Case.  II. — Hannah  T.,  7  years  old,  was  taken  sick  with  fever,  complained  of 
being  tired,  and  was  very  thirsty.  She  had  anorexia  and  was  inclined  to  constipation. 
She  also  complained  of  headacJies.  When  first  seen  by  m  >  her  temperature  was 
103.4°  F.  in  the  mouth,  the  pulse  108,  respiration  34.  She  had  a  very  coated  tongue; 
the  throat  was  dry.  there  were  no  patches  visible.  There  was  no  history  of  exposure 
to  ccmtagious  diseases;  a  gastric  catarrh  was  suspected.  The  respiration  aiul  pulse 
ratio  suggested  a  pulmonary  complication. 

The  physical  examination  of  the  thorax  give  no  exidence  of  consolidation, 
merely  roughened,  harsh  breathing,  some  rhoncbi  and  slight  resistance  of  percussing 
the  right  apex  anteriorly.  No  diagnosis  except  "fever"  was  made.  I  ordered 
calomel  1  grain  with  powdered  rhubarb  3  grains.  Citrate  of  magnesia  ^\■as  given 
for  the  thirst.  A  fluid  diet,  consisting  of  equal  parts  of  Seltzer  and  milk,  with 
sponging  of  the  chest  with  alcob.ol  and  water  everv  hour,  and  cool  clotlis,  moistened 


CEREBRAL  PNEUMONIA.  505 

with  evaporating  lotions  like  bay  rum  or  Florida  water,  to  the  forehead  were  also 
ordered. 

I  examined  a  specimen  of  urine  which  contained  nothing  abnormal.  On  the 
following  morning,  twelve  hours  after  my  first  visit,  the  temperature  by  rectum 
was  104.4°  F.,  pulse  172,  respiration  68  while  asleep.  The  bowels  had  been 
thoroughly  cleaned,  still  there  was  no  evidence  of  pneumonia,  but  the  child  seemed 
to  be  greatly  depressed.  There  was  marked  apathy;  the  child  was  very  restless  and 
had  not  slept.  Constant  twitchings  of  the  muscles  of  the  face  and  extremities 
occurred;  the  child  cried  out  while  in  the  stupor,  refused  food,  attempted  to  bite 
and  screamed  loudly.  The  patellar  reflexes  were  both  present,  the  pupils  reacted 
normally,  the  head  was  not  retracted  nor  were  the  muscles  rigid.  There  was  no 
opisthotonos;  the  child  could  be  roused  by  loud  talking,  or  by  being  touched. 
The  temperature  in  the  evening  was  106.2°  F.  by  rectum,  the  pulse  124,  respiration 
40.  One  drop  doses  of  tincture  of  aconite  were  given  every  hour  for  eight  hours 
and  had  no  effect  on  the  temperature,  but  did  seem  to  reduce  the  pulse-rate  and 
steady  the  heart's  action. 

The  cold  pack  was  ordered,  to  be  renewed  eveiy  half-hour  until  the  temperature 
dropped  to  102°  F.  Freshly  prepared  spiritus  mindeverus,  one-half  teaspoonful  every 
half-hour  until  the  temperature  remained  at  102°  F.,  was  also  ordered.  Warm 
mustard  foot-baths  were  ordered  to  stimulate  the  circulation,  and  whisky  with  milk 
(3j  to  5iv),  whenever  possible.  No  distinct  evidences  of  pneumonia  were  obtained  on 
auscultation  or  percussion. 

The  temperature  continued  to  rise,  until  106°  F.  was  reached.  Dry  cups  were 
applied  over  the  posterior  portion  of  the  lungs,  also  an  ice-cap  to  the  head.  Colon 
flushings  with  water  at  a  temperature  of  00°  F.  were  also  ordered,  to  be 
repeated  every  three  hours.  These  seemed  to  have  a  very  soothing  effect  on  the 
nervous  system.  The  child  was  much  quieter  after  them  and  the  temperature  was 
gradually  reduced. 

Frequently  after  a  cool  tub  bath,  combined  with  a  cold  pack,  the  temperature 
dropped  three  to  four  degrees.  (Fig.  156.)  Creosote  carbonate,  in  3-drop  doses, 
was  ordered  every  three  hours,  to  be  given  in  milk,  soup  or  chocolate.  This  dose 
was  increased  gradually  by  the  addition  of  one  drop  each  day,  until  the  child 
received  ten  drops  every  four  hours.  No  systemic  disturbance  was  noticed,  there 
was  no  discoloration  of  the  urine  and  no  toxic  symptoms  resulted  from  the  creosote 
treatment.  A  decided  antithennic  effect  without  cardiac  depression  was  noticed. 
(A  convenient  way  of  giving  the  creosote  is  to  add  the  drops  to  some  Tokay  wine 
or  to  combine  it  with  whisky  and  water.) 

Creosote  steam  inhalations  were  also  ordered.  Beechwood  creosote,  about  a 
teaspoonful  to  a  pint  of  boiling  water,  was  permitted  to  steam  on  a  table  several 
feet  from  the  patient.  This  powerful  vapor  soon  impregnated  the  air  so  that  the 
creosote  could  be  smelt  throughout  the  whole  apartment.  It  certainly  acted  very 
well,  not  only  on  the  temperature  but  also  in  loosening  viscid  secretion. 

The  vital  point  in  the  treatment  consisted  in  giving  a  supporting  diet  of  eggs 
beaten  up  with  sugar  and  Tokay  wine,  concentrated  soups,  and  milk  pre-digestcd  with 
peptonizing  powder.  Malt  extract  was  given  as  a  restorative  and  also  for  its 
diastasic  effect.  The  treatment  was  continued  until  the  child's  temperature  remained 
normal  for  several  days,  when  all  forms  of  creosote  were  discontinued. 

It  is  interesting  to  note  that  very  great  depression  of  the  nervous  system, 
violent  twitchings  of  the  muscles  and  talking  aloud  while  asleep,  continued  for 
several  weeks  after  convalescence  was  established.  The  child  slept  at  least  twenty 
hours  out  of  the  twenty-four  for  fully  one  week.  It  was  at  times  diflTicult  to  arouse 
her  to   take  nourishment.      This  great  stupor   was  evidently  due  to  the  profound 


506  i'JH'^  INFECTIOUS  DISEASES. 

toxisemiii  Avhieli  existed.  The  urine,  whicli  was  frequently  examined,  showed  an 
excess  of  pliosphates,  gave  a  strong  diazo  reaction,  contained  neither  albumin  nor 
sugar.  The  child  was  discharged  after  eight  weeks  and  is  in  good  health  to-day. 
The  following  sj'mptoms  were  the  most  noteworthy  in  the  cases  reported: — 
((/)  I'nilateral  spasms,  twitchings  of  the  muscles  of  the  shoulder  and  the 
arm.  and  of  the  leg  and  foot,  were  constantly  present.  (6)  Twitchings  of  the 
muscles  of  the  eye  and  a  constant  rolling  of  the  eyeball,  (c)  The  head  was  thrown 
backward.  (d)  The  patellar  reflex  Avas  absent  on  the  afTected  side.  (c)  The 
plantar  reflex  was  slight  on  the  affected  side.  (/")  Distinct  evidences  of  pneumonia, 
bronchial  breathing  and  marked  dullness  on  percussion.  (g)  Convulsions  and 
marked  stupor  later  in  the  disease,  (h)  When  the  crisis  ajipeared  in  the  pneumonia, 
the  cerebral  symptoms  subsided.  (/)  Marked  nervous  depression  and  extreme 
hyperaesthesia  of  the  body,  which  continued  for  weeks  after  all  inflammatory  symp- 
toms had  subsided. 

Schlesinger,  in  studying  tliis  disease,  noted  that  it  existed  cliiefly  in 
children  between  the  third  and  sixth  years. 

In  acute  apical  pneumonia  we  usually  note  cerebral  symptoms  due  to 
the  irritation  of  tlie  cervical  ganglion.  These  sjanptoms  subside  with  the 
crisis  of  pneumonia.  They  must  not  be  confounded  with  meningitis,  which 
is  a  distinct  disease,  althougli  a  frequent  complication  of  pneumonia. 

Symptoms  and  Course. — The  disease  is  usually  ushered  in  with  con- 
vulsions. At  times  vomiting  and  diarrhoea  may  be  the  first  symptoms 
noticed.  Chills  arc  very  rarely  seen  in  chihlren.  The  cheeks  are  usually 
very  red  and  show  the  characteristic  flush  so  well  known  in  adult  pneu- 
monia. The  respirations  are  increased,  the  pulse  is  accelerated,  and  the 
temperature  rises.  One  of  the  most  important  diagnostic  points  and  one 
upon  which  I  lay  great  stress  is  the  "raiio  hettveen  tlm  pulse  and  respira- 
tion." Xormally  the  ratio  is  1  to  -1,  and  when  this  ratio  is  increased,  as, 
for  example,  wlien  there  are  GO  respirations  and  140  pulse  beats,  then  the 
ratio  of  1  to  4,  which  normally  existed,  is  certainly  disturbed.  By  this 
distur])ed  ratio  alone  we  can  frequently  nuike  a  diagnosis  by  the  process  of 
cxclusicm.  Es])ecially  is  this  true  in  tliose  cases  of  "central  pneumonia"  in 
which  tlie  disease  develops  in  the  center  of  the  lung  and  gradually  spreads 
toward  the  periphery.  When  such  central  pneumonia  exists,  the  physical 
signs  will  be  so  masked  that  Iti'oneliial  breathing  will  be  hardly  discern- 
ible. The  temperature  will  suddenly  rise  to  102°,  103°,  and  frequently 
to  105°  F.  The  temperature  in  rachitic  children  will  sometimes  rise 
to  10()°  and  107°  F.  It  is  this  class  of  cases  that  show  the  most  severe 
form  of  depression  from  irritation  of  the  thermic  centers.  In  these  rachitic 
children  we  usually  note  that  the  invasion  of  pneumonia  begins  with  a  con- 
vulsion or  a  series  of  convulsions. 

Children  old  enougli  will  frequently  complain  of  abdominal  pains. 
Thus  we  must  not  be  misled  by  gastric  or  gastro-intestinal  symptoms  until 
we  can  exchule  the  lungs  as  the  seat  of  the  disease.  The  physical  sign  most 
commonly  associated  with  this  disease  is  dullness  on  percussion  over  the 


CEREBRAL  PNEUMONIA.  607 

affected  area  of  the  lung.  In  addition  thereto  there  will  be  bronchial  breath- 
ing. If  the  child  cry,  a  loud  bronchophony  will  be  heard.  There  will  also 
be  an  increased  vocal  fremitus.  These  symptoms  usually  remain  the  same 
for  a  few  days,  although  they  may  increase  in  intensity. 

Between  the  sixth  and  the  ninth  day,  rarely  earlier  and  very  rarely 
later,  a  crisis  takes  place  in  which  the  temperature  will  suddenly  drop  to 
normal.  The  patient  will  be  covered  with  a  profuse  perspiration;  the 
pulse,  which  formerly  was  full,  bounding  and  accelerated,  will  be  found 
smaller  and  less  frequent.  The  former  flush  which  existed  will  give  place 
to  a  distinct  pallor  of  the  skin,  and  the  observing  physician  will  note  a 
decided  change  in  the  patient.  This  condition,  known  as  the  crisis,  may 
come  on  suddenly  or  gradually.  In  some  cases  the  fever  drops  slowly — 
i.e.,  by  lysis,  until  normal  is  reached. 

Pulse. — The  pulse-rate  is  one  which  is  a  very  important  factor  in  con- 
nection with  this  disease.  While  it  may  be  120  and  be  quite  regular  in 
action,  it  is  not  uncommon  to  find  the  pulse-rate  140,  and  even  160.  The 
frequency  of  the  pulse  is  not  as  important  a  factor  in  determining  the 
progress  of  this  disease  as  is  the  character  of  the  pulse.  Thus,  to  illus- 
trate, if  a  pulse  is  not  frequent,  but  is  weak  and  arythmic,  such  a  patient 
should  be  regarded  as  in  imminent  danger  and  requires  very  frequent  and 
careful  stimulation.  A  condition  of  collapse  may  be  looked  for  in  such  a 
patient,  and  treatment  directed  to  the  prevention  of  the  same  is  indicated. 
If  the  pulse-rate  has  been  120,  and  it  suddenly  increases  to  140  or  more, 
then  some  complication  must  be  suspected  and  the  child  carefully  exam- 
ined to  determine  the  cause  of  this  sudden  increase  of  the  pulse-rate. 

Respiration. — The  whole  respiratory  condition  is  superficial  and  seems 
to  call  the  accessory  respiratory  muscles  into  play.  When  the  respiration 
is  above  40  per  minute,  the  diagnosis  is  usually  very  positive. 

Lack  of  Expansion. — A  lack  of  expansion  may  also  be  noticed.  It 
involves  the  whole  of  the  affected  side  and  is  not  limited  to  the  sub- 
clavicular region.  In  pneumonia  this  lack  of  expansion  in  the  subclavicular 
region  is  marked,  even  though  the  inflammatory  process  is  situated  at  the 
base.  It  can  be  observed  as  early  as  the  first  day,  and  lasts  throughout  the 
entire  course  of  the  disease.  This  early  appearance  of  the  sign  is  of  especial 
importance,  since  the  physical  signs  of  involvement  of  the  lung  are  so 
frequently  delayed  in  cases  of  infantile  pneumonia. 

The  sign  is  best  elicited  in  the  dorsal  position,  and  is  easily  seen  on  the 
exposed  chest  in  quick  respiration. 

One  writer  says  he  has  recognized  by  this  sign  alone  pneumonia  occur- 
ring in  a  supposed  case  of  appendicitis,  and  also  has  discovered  pneumonia 
complicating  typhoid  and  influenza. 

The  Temperature. — A  rise  of  temperature  usually  implies  the  invasion 
of  the  specific  micro-organism  and  hence  is  one  of  the  earliest  symptoma 


508 


THE  l-NFECTlors  DISEASES. 


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Fig.  157. — Lol)ar  Pneumonia  of  a  Severe^ 
Type,  seen  by  in<'  in  consultation  with  Dr.  S. 
]\I.  Landsmann.  Tlie  elTect  of  the  poison  is 
easily  seen  by  studying  the  pulse-rate.  Case 
Recovered.      (Original.) 

1  See  '"Blood  in  Pneumonia,"  page  728, 


I)  10.-)°  1\,  and  remains  so  itntil 
mission;  thus,  we  find  the  tem- 
perature ahout  one  degree  lower 
iu  the  nioiiiinij  than  w^e  do  in 
the  e^•euin<r.  In  pneumonia 
we  frequently  lind  a  condition 
known  as  tlie  "'procrisis."  Tliis 
procritical  stage  exists  one  day 
Ijefore  the  crisis,  as  a  rule. 
I'he  temperature  will  suddenly 
fall  to  normal  on  the  day  pre- 
ceding the  crisis.  It  has  a  valu- 
a!)le  prognostic  significance, 
showing  that  the  inflammatory 
stage  has  now  terminated. 

Tlic  Blood  ImPneuiiioniaA 
— Baginskv  maintains  that  the 
examination  of  the  Idood  will 
show  the  progress  of  this  dis- 
ease, and  lie  helieves  that  the 
leucoeytosis  so  common  in  this 
disease  has  an  important  bear- 
ing on  the  prognosis  of  this 
condition.  Felsenthal  and 
Sehlesinger,  also  ]\[onti,  Berg- 
grihi,  and  Loos,  have  found 
that  there  is  an  increase  of 
the  ])olynuclear  cells,  whereas 
the  eosinophile  cells  disappear. 
When  the  temperature  returns 
to  normal  during  the  crisis  in 
pneumonia,  the  leucoeytosis 
which  formerly  existed  also 
disappears.  Thus  some  au- 
thors speak  of  a  "blood  crisis." 

Tlie  Urine. — This  is  fre- 
quently high-colored  and  very 
scanty,  es])ecially  so  during 
the  height  of  the  disease.  It 
also  has  a  very  high  specific 
gravity  and  frequently  con- 
tains albumin.  Acetone  can 
also    fi-e(pu'ntly    he    found    in 


CEREBRAL  PNEUMONIA.  509 

the  urine.  The  alhuniin  frequently  disappears  after  the  crisis.  The 
jjhosphates  seem  increased,  though  some  authors  maintain  that  they  are 
decreased  during  the  progress  of  this  inflammatory  type  of  disease.  The 
diazo  reaction  is  only  found  in  that  form  of  pneumonia  Avhich  seems  to 
have  a  typhoid  tendency.  Indican  is  very  rarely  or  never  found  unles^s 
there  is  some  form  of  intestinal  putrefactive  complication. 

Relapse. — It  is  not  infrequent  to  have  one  and  the  same  area  of  lung 
reinvaded;  thus  the  disease  may  run  a  second  course  over  the  same  portion 
of  the  lung  just  as  it  did  in  the  first  attack. 

Diagnosis. — -The  diagnosis  of  pneumonia  is  easy  when  the  physical 
symptoms  of  dullness  on  percussion,  bronchial  breathing,  moist  rales,  and 
bronchophony  are  shown.  These  symptoms  are  not  always  present  and  are 
frequently  absent  during  the  first  few  days  of  the  disease.  The  diagnosis 
can  be  made  by  the  disturbed  ratio  between  pulse  and  respiration,  as  pre- 
viously noted.  In  addition  thereto,  the  peculiar  character  of  the  respira- 
tion, added  to  the  cough,  will  certainly  aid  in  establishing  the  diagnosis. 
The  vital  point  to  remember  is  that  normally,  bronchial  breathing  is  heard 
posteriorly  between  the  scapulae  and  also  in  the  regio  supraspinata  dextra. 
We  must  also  remember  that  dullness  on  percussion  appears  somewhat 
higher  on  the  right  side  posteriorly  in  the  lower  lobe  tlian  on  the  left  side. 
'J'he  positive  diagnosis  can  therefore  only  be  made  by  noting  the  ph3^sical 
signs  in  the  lungs  and  excluding  the  symptoms  pointing  to  a  gastric  catarrh, 
to  a  typhoid  fever  or  a  meningitis. 

Atalectasis  pulmonum  can  easily  be  differentiated  from  pneumonia  by 
the  absence  of  fever  and  by  the  marked  difference  in  the  dullness  on  per- 
cussion and  usually  by  the  absence  of  bronchial  breathing.  When  fever 
recurs  after  it  has  apparently  terminated,  some  complication  must  be  sus- 
pected. Symptoms  pointing  to  a  pleuritic  effusion  are,  dullness  on  percus- 
sion and  diminished  respiratory  murnmr  over  the  affected  area.  Gangrene 
of  the  lungs  can  usually  be  detected  by  the  odor  of  the  breath  and  the  asso- 
ciated condition  of  collapse.  If  the  condition  assumes  a  chronic  type  and 
is  associated  with  headache  and  fever,  and  if  the  child,  in  addition,  com- 
mences to  emaciate,  then  we  may  suspect  the  development  of  tuberculosis. 
To  render  such  diagnosis  positive,  some  of  the  sputum  or  expectoration 
should  be  examined  for  the  presence  of  tubercle  bacilli,  the  presence  of 
which  will  establish  the  diagnosis.  The  absence  of  tubercle  bacilli  in  the 
sputum  does  not  necessarily  mean  that  tuberculosis  is  absent. 

The  Prognosis. — The  prognosis  of  croupous  pneuuionia  is  relatively 
good.  Out  of  173  cases  reported  by  Baginsky,  of  Berlin,  4  per  cent.  died. 
These  latter  children  were  very  poorly  nourished. 

Fatal  cases  may  be  expected  in  bottle-fed  infants  rather  than  in  breast- 
fed infants.  An  abnormally  developed  thorax  so  common  in  rickets,  luis  iin 
important  bearing  on  the  prognosis  of  this  disease.     Pigeon-breasted  and 


510  THE  INFECTIOUS  DISEASES. 

narrow-chested  infants  having  an  improperly  developed  lung  space,  are  more 
prone  to  a  fatal  termination. 

The  development  of  symptoms  of  tuberculosis  or  abscess  of  the  lung 
or  the  extension  of  a  pneumonia  and  the  continuation  of  the  same,  will  mean 
a  depression  of  the  heart's  action  and  an  inhibiting  of  the  recuperative 
tendency.  The  vital  point  will  be  the  question  of  nutrition.  The  greater 
the  amount  of  food  taken  the  better  will  be  the  chance  for  the  patient's 
recovery;  thus  the  maxim  in  treating  a  pneumonia,  "Feed  the  stomach/* 
is  one  that  I  have  learned  to  indorse  and  verify. 

Treatment. — The  most  important  symptoms  to  be  remembered  in  the 
treatment  of  this  disease  are  the  condition  of  the  heart,  the  pulse-rate,  the 
respirations,  the  temperature,  and  the  condition  of  the  kidneys,  to  be  noted 
by  the  quantity  and  the  quality  of  the  urine  secreted. 

Isolate  the  Child. — As  lobar  pneumonia  is  an  acute  infectious  disease 
caused  by  the  invasion  of  the  pneumococcus,  it  is  transmittible.  Our  first 
duty  is  to  isolate.  A  case  of  pneumonia  should  be  isolated  as  strictly  as  a 
case  of  diphtheria.  All  healthy  persons  should  be  excluded,  be  they  friends 
or  family.    It  is  best  to  let  them  know  that  this  disease  can  be  disseminated. 

In  the  treatment  of  pneumonia  we  must  remember  that  toxaemia  and 
high  temperature  will  produce  degeneration  of  the  muscular  fiber  of  the 
heart,  which,  if  prolonged,  will  result  in  heart  failure.  Hence  our  treat- 
ment must  be  directed  to  lowering  the  temperature  and  to  control  the 
inflammatory  process  before  stagnation  of  the  blood  and  hepatization  have 
taken  place,  thus  aiming  to  retain  the  integrity  of  the  respiratory  tract. 

Any  interference  with  the  proper  action  of  the  respiratory  apparatus 
leads  to  overloading  and  ultimate  failure  of  the  right  side  of  the  heart. 
Hence  we  must  seek  to  keep  up  the  respiratory  pump  by  lessening  the  fre- 
quency and  increasiug  the  depth  of  the  respirations. 

A  great  many  cases  will  get  well  without  treatment.  This  is  called  the 
"self-limited"  condition.  The  disease  simply  runs  its  course,  and  if  the 
patient  is  properly  fed,  strengthened,  and  guarded,  a  favorable  fermination 
may  be  expected.  On  the  other  hand  there  are  certain  symptoms  which 
demand  treatment.  For  example,  hyperpyrexia  will  require  treatment,  espe- 
cially so,  as  the  continuation  of  the  same  may  be  the  means  of  developing 
disturbances  resulting  in  convulsions.  My  preference  has  always  been  for 
the  use  of  cold  externally.  If  cyanosis  exists  then  warm  flaxseed  poultices 
may  be  tried. 

The  sudden  application  of  cold  externally  causes  a  deep  inspiration  and 
consequent  forcing  of  air  through  the  alveoli,  thus  preventing  atelectasis. 
The  air  surrounding  the  child  should  be  kept  moist  with  steam  from  a  tea- 
kettle, having  a  long  spout  directed  toward  the  child  (Fig.  137). 

The  following  case  was  attended  by  me  in  the  babies'  ward  of  the  New 
York  Post-Graduate  Hospital: — 


CEREBRAL  PNEUMONIA.  511 

Child  F.  A.,  5  years  old.  My  attention  was  called  on  August  12th  to  a  tem- 
perature of  99  Vs"  F.,  which  rose  to  104'/,°  F.,  by  8.30  the  following  evening.  Per- 
cussion showed  dullness  over  a  coinplete  lobe  of  the  left  lung,  bronchial  breathing, 
cough,  no  expectoration.  The  respiration  rose  from  36  in  the  morning  to  50 
in  the  evening,  and  the  pulse  from  120  to  130  per  minute.  Until  the  diagnosis 
was  positive  the  child  was  put  on  the  expectant  plan  of  treatment.  The 
temperature  rose  to  105°  F.  on  the  second  day,  in  spite  of  sponge  baths  con- 
sisting of  equal  parts  of  alcohol  and  water.  After  a  few  hours  the  temperature 
increased  to  its  former  height,  sometimes  going  beyond  that,  prior  to  the  sponge 
bath. 

In  order  then  to  have  a  more  lasting  effect,  it  was  deemed  necessary  to  give 
the  tub  baths^  that  is,  to  immerse  the  child  from  the  neck  to  the  feet  in  water  of 
about  90°  F.  and  then  adding  ice  until  the  temperature  of  the  bath  is  70°  F.  The 
child  was  kept  in  the  bath  from  two  to  five  minutes. 

The  first  tub  bath  brought  the  temperature  from  104  Vb°  F.  to  100°  F.  This 
drop  lasted  about  two  hours.  The  temperature  did  not  rise  more  than  two  degrees 
until  the  following  afternoon  at  4  p.m.,  when  it  reached  104  Vj°  F.  This  is  a  natural 
course  in  a  severe  pneumonia.  The  second  tub  bath  had  the  effect  of  lowering  the 
temperature  from  104  7,°  F.  to  101  Vb"  F.,  a  decrease  of  3  V»°  F.  in  one  hour. 

On  the  19th  of  August,  the  eighth  day  of  the  disease,  the  temperature  reached 
104  */»"  F.  at  6  P.M.  A  tub  bath  given  brought  the  temperature  to  103°  F.  at  7  p.m., 
a  fall  of  1  Vb"  F.  in  one  hour.  Tliis  same  temperature  continued  until  9  p.m.,  after 
which  it  began  to  fall,  reaching  normal  on  the  following  day,  the  ninth  day  of 
disease.  The  boy  was  discharged  cured.  He  was  entirely  well  when  I  last  heard  of 
him. 

In  the  above  case,  true  symptomatic  treatment  was  carried  out.  The  severe 
cough  received  an  expectorant  with  an  anodyne  (codeine)  when  necessary  to  relieve 
pain.  Bowels  and  bladder  were  carefully  watched.  Stimulants  given  when  required 
— no  antipyretics.  Diluted  milk  and  whey,  every  three  hours.  Cool  water  when- 
ever thirsty. 

Drug  Treatment. — When  high  fever  persists  in  a  weakened  child  with 
very  low  resisting  power,  such  fever  must  be  reduced.  The  child's  system 
must  be  carefully  watched  while  fever  is  in  progress.  One  child  will  tole- 
rate a  temperature  of  105°  F.,  laugh  and  play,  and  take  its  food  regularly, 
while  another  child  in  a  similar  pulmonary  condition  will  show  extensive 
cerebral  irritation,  somnolence,  tremor,  twitching  of  the  muscles,  and  pos- 
sibly convulsions  at  a  temperature  of  103°  or  104°  F.  In  the  latter  instance 
it  shows  that  the  poison  from  the  pneumococcus  infection  has  overwhelmed 
the  nerve  centers  governing  heat  production,  and  in  such  instances  when 
decided  nervous  or  cerebral  symptoms  present  themselves,  "a  reduction  of 
temperature  is  demanded,"  or  we  must  not  be  surprised  to  see  convulsions 
set  in,  with  probably  a  fatal  termination. 

How  Shall  We  Reduce  the  Temperature  in  Children? — When  we  con- 
sider that  antipyretic  drugs  depress  the  nerve  centers  governing  heat  pro- 
duction and  increase  the  work  of  the  emunctories,  already  loaded  down  by 
poison  brought  to  them  for  elimination,  it  can  be  seen  that  their  use  is 
contraindicated.    Those  who  believe  in  phagocytosis  may  be  reminded  that 


612  THE  INFECTIOUS  DISEASES. 

antipyretics  arrest  the  development  of  leucocytosis,  and  thus  remove  one  of 
the  means  of  destroying  the  germs  of  the  disease  according  to  one  theory, 
or  the  antitoxin  generated  or  developed  according  to  another  (Hobart  A. 
Hare) . 

Jacubowitsch  and  MuUer  and  many  others  have  proved  conclusively 
that  antipyrine  decreases  the  elimination  of  urea  by  the  urine.  It  also 
decreases  the  urinary  flow,  vehich  is  a  very  harmful  effect,  when  we  con- 
sider the  great  importance  of  eliminating  effete  matter  from  the  body. 
That  antipyretics  depress  the  heart's  action  is  only  too  well  known,  there- 
fore, rather  than  to  combine  them  with  musk,  camphor,  or  other  cardiac 
stimulants,  I  have  discarded  them. 

When  drugs  are  used  as  antipyretics  the  coal-tar  products  are  usually 
the  ones  suggested.  Lactophenin,  antipyrine,  phenacetin,  salol,  sali- 
pyrine,  and  quinine  are  among  the  more  common  antipyretic  measures 
used.  The  tincture  of  aconite,  in  1-minim  doses,  repeated  every  hour, 
has  a  remarkably  good  effect  on  this  disease.  In  addition  thereto,  spirits 
of  mindereri  in  half-teaspoonful  doses,  repeated  every  hour,  will  have  a 
very  good  diaphoretic  effect.  Dover's  powder  will  relieve  cough  and  will 
also  aid  diaphoresis. 

For  difficilt  breathing  nothing  will  serve  as  well  as  local  depletion. 
For  this  purpose  the  application  of  dry  cups  over  the  affected  areas  of  the 
lung  will  afford  in  some  instances  immediate  relief.  D17  cupping  may 
be  repeated  in  severe  dyspnoea  in  twelve  hours  if  necessary.  Tincture  of 
iodine  applied  locally  over  the  area  of  the  lung  affected  will  also  be  advan- 
tageous in  some  instances. 

If  convulsions  persist  an  ice-bag  applied  over  the  head  and  also  at  the 
nape  of  the  neck  will  be  very  valuable. 

I  frequently  use  one  or  two  leeches  applied  over  the  mastoid  process 
of  the  temporal  bone  and  permit  very  free  bleeding.  This  is  especially 
indicated  when  there  is  intense  engorgement  of  the  brain  with  marked 
stupor  and  coma.  We  can  frequently  relieve  congestion  by  the  application 
of  leeches  to  the  alae  nasi.  A  simple  but  most  effective  remedy  is  the  use 
of  mustard  foot-baths  frequently  given. 

To  relieve  the  cerebral  hyperaemia,  calomel  in  */io-grain  doses,  and 
increased,  may  be  repeated  until  liquid  stools  have  been  produced.  It  is 
one  of  our  most  valuable  remedies  and  should  be  used  at  the  onset  of  a 
suspected  pneumonia.  Attention  to  the  stomach  and  bowels  will  frequently 
be  the  means  of  saving  the  life  of  the  patient.  I  insist  upon  a  loose  con- 
dition of  the  bowels,  and  if  the  same  cannot  be  produced  by  the  admin- 
istration of  calomel,  then  an  enema  should  be  given  by  flushing  the  colon 
as  often  as  once  in  twelve  hours  to  cleanse  the  parts.  When  children  are 
old  enough,  then  one  of  the  most  valuable  remedies  is  to  give  copious  drinks 
of  citrate  of  magnesia.  This  will  not  only  quench  the  thirst,  but  will  act 
as  a  laxative,  and  in  addition  thereto  stimulate  the  secretion  of  urine. 


CEREBRAL  PNEUMONIA.  513 

We  find  therefore  that  the  emunctories  require  especial  stimulation  and 
attention  during  the  course  of  lobar  pneumonia. 

In  no  disease  is  strychnine  more  valuable  than  during  the  course 
of  pneumonia.  Very  small  doses  of  only  ^/joo  or  ^/^^q  grain,  repeated 
every  hour,  may  be  given  without  fear  during  the  progress  of  this  dis- 
ease. The  question  of  stimulation  is  one  of  individuality.  Each  case 
must  be  treated  on  its  own  merits  and  the  individual  condition  studied. 
When  the  heart's  action  is  feeble  and  the  pulse  is  thready,  whisky  must 
be  given.  In  some  cases  five  to  thirty  drops  of  good  whisky  may  be 
given  as  often  as  every  half-hour  until  the  pulse  responds  to  the  stim- 
ulant. I  frequently  combine  strychnine  with  whisky.  In  other  cases 
champagne  in  half-drachm  or  drachm  doses  will  be  found  far  more 
efi;ectual.  Some  children  ohject  to  the  taste  of  whisky  or  champagne,  but 
will  take  a  sweetened  wine.  In  such  cases  give  good,  old  Tokay  in  half- 
drachm  doses  as  often  as  is  required.  When  there  is  an  aversion  to  the 
taking  of  medicine  or  if  the  child  rebel  against  stimulation  by  the  mouth 
and  it  is  urgently  called  for,  then  half  a  teacupful  of  hot  water,  temperature 
of  100°  F.,  to  105°  F.,  to  which  a  teaspoonful  of  either  whisky  or  alcohol  is 
added,  may  be  thrown  into  the  colon  by  means  of  a  colon  tube.  Hypo- 
dermic medication  must  not  be  overlooked,  and  frequently  it  is  wise  to  use 
whisky,  ether,  or  spirits  of  camphor.  A  valuable  method  of  giving  camphor 
hypodermicaily  is  by  injecting  camphorated  oil,  from  5  to  15  minims.  Musk 
is  one  of  our  best  cardiac  stimulants,  and  if  the  pulse-rate  is  feeble  it  may 
be  given  in  1  to  5-drop  doses,  repeated  in  three  or  four  hours,  if  necessary. 

Hygienic  Treatment:  Room  Temperature. — One  of  the  most  impor- 
tant factors  is  the  regulation  of  the  temperature  of  the  room.  Every  child 
having  a  pneumonia  should  be  put  into  a  room  having  a  temperature  of  65* 
to  70°  F.  An  equable  temperature  should  be  maintained,  as  the  same  is 
very  grateful  during  the  febrile  stage  of  this  disease.  Fresh  air  should  al- 
ways be  admitted. 

Oxygen. — When  severe  dyspnoea  occurs  and  if  cyanosis  exists,  then 
oxygen  inhalations  may  be  required.  Under  these  conditions  several  res- 
pirations should  be  given  every  few  minutes  until  the  lips  lose  their  cyanotic 
appearance  and  again  have  their  natural  color. 

Sponge  Baths. — The  surface  of  the  body  should  be  sponged  with  tepid 
water  every  day.  Equal  parts  of  alcohol  and  water  are  grateful  to  the 
patient,  and  should  be  used  every  hour  if  the  temperature  requires  it.  If, 
however,  the  temperature  is  not  high,  then  a  sponge  bath  to  which  a  little 
alcohol  has  been  added  will  be  grateful,  and  may  be  given  every  morning 
and  evening. 

Another  valuable  means  of  reducing  the  temperature  is  by  sponging 
every  hour  with  acetic  ether.  This  must  be  cautiously  used,  owing  to  ita 
volatile  and  inflammable  tendencies. 


514  THE  INFECTIOUS  DISEASES. 

The  Oil-silk  Jacket. — This  jacket  is  valuable  when  we  desire  a  dia- 
phoretic effect.  It  also  prevents  the  chilling  of  the  surface  of  the  lung  by 
maintaining  a  uniform  temperature.  The  details  of  making  this  jacket 
can  be  found  in  the  article  on  "Broncho-pneumonia/'  page  462. 

Dietetic  Treatment. — As  previously  stated,  the  prognosis  in  this  con- 
dition depends  on  the  amount  of  food  the  patient  will  take.  A  milk  diet 
should  be  prescribed.  Buttermilk,  kumyss,  zoolak,  rice  and  milk,  farina 
and  milk,  oatmeal  and  milk,  and  cold  foods,  such  as  cornstarch  pudding, 
rice  pudding,  and  tapioca  pudding,  are  very  grateful.  If  the  child  is  very 
thirsty  and  is  over  2  years  old,  ice  cream  may  be  permitted  very  sparingly. 
This  is  very  grateful  to  the  little  patient,  and  if  made  from  fresh  cream  is 
very  nutritious.  Concentrated  soups,  chicken  broth,  and  veal  broth  may 
be  permitted.  So  also  calf's  foot  jelly,  chicken  jelly,  albumin  in  the  form 
of  raw  white  of  egg,  to  which  some  sugar  is  added,  may  be  given.  A  soft- 
boiled  egg  or  raw  yolk  of  egg  with  sugar  may  also  be  given. 

The  interval  between  each  feeding  must  be  prolonged,  owing  to  the 
subnormal  condition  of  the  digestive  tract.  If  children  are  fed  from 
the  bottle,  or  if  they  are  nursing  babies,  then  they  should  be  fed  with  a 
longer  interval  than  previous  to  the  time  of  this  illness;  for  example,  if 
the  infant  has  been  given  the  breast  every  three  hours,  it  is  a  good  rule  to 
extend  the  nursing  time  to  three  and  one-half  or  four  hours,  if  it  is  pos- 
sible. In  this  manner  we  will  not  only  aid  in  the  assimilation  of  the  food, 
but  frequently  prevent  stagnation  of  milk  which  had  been  previously  taken. 

Night  Feeding. — The  rule  which  governs  the  feeding  of  healthy  chil- 
dren cannot  be  applied  to  children  suffering  with  pneumonia.  During  the 
febrile  stage  large  quantities  of  liquids  are  demanded.  In  order  to  overcome 
the  cardiac  depression  good  nourishment  is  indicated.  A  nursling  suffering 
with  pneumonia  should  be  given  the  breast  several  times  during  the  night. 
Bottle-fed  infants  may  also  receive  some  nutrition  every,  three  or  four  hours 
during  the  night.  A  favorable  termination  in  this  disease  can  only  be 
expected  when  the  depressed  vitality  is  stimulated  by  nutrition. 

Tuberculous  Pneumonia. 

There  are  four  pathological  conditions  which  illustrate  the  various 
stages  of  the  disease;  they  are:  first,  a  bronchitis  with  rhonchi  scattered 
through  the  chest;  second,  small  areas  of  consolidation  or  partial  consolida- 
tion; third,  complete  consolidation  with  bronchial  breathing,  dull  areas 
on  percussion;   fourth,  excavation  with  cavernous  or  amphoric  breathing. 

In  its  early  stages  the  disease  resembles  broncho-pneumonia. 

Cavities  are  frequently  found  post-mortem.  They  are  difficult  to  find 
in  young  children  under  3  years  of  age.  On  the  other  hand,  children  over 
8  or  9  years  have  cavities  which  can  be  recognized  as  early  as  in  the  adult. 


TUBERCULOUS  PNEUMONIA.  515 

Holt  states  that  "the  reason  why  in  infancy  cavities  are  so  seldom  recog- 
nized during  life,  is  because  they  are  generally  small,  often  centrally  located, 
nearly  always  filled  with  thick  pus  or  cheesy  matter,  and  rarely  communicate 
freely  with  the  bronchi.  On  the  other  hand  it  is  very  common  to  find 
signs  in  young  children  which,  if  heard  in  adults,  would  be  regarded  as 
almost  positive  evidence  of  a  cavity,  although  none  is  present.  These 
signs  are  cracked-pot  resonance  and  cavernous  breathing.  They  are  not 
usually  due  to  bronchiectasis,  since  this  condition  belongs  to  chronic  cases, 
and  especially  to  older  children,  but  most  frequently  to  consolidation  about 
a  large  bronchus  superficially  situated,  viz. :  below  the  clavicle,  high  in  the 
axilla,  and  in  the  interscapular  region.  The  wide  area  over  which  this 
broncho-cavernous  breathing  is  heard  is  one  of  the  most  striking  points  of 
difference  from  the  signs  of  a  cavity." 

Course. — There  are  two  types  of  cases:  First,  rapid  cases  or  those 
terminating  very  quickly;  second,  those  assuming  a  chronic  course  (pro- 
tracted cases). 

1.  The  Rapid  Type. — The  pathological  process  is  a  bronchitis  affecting 
the  smaller  tubes  surrounded  by  areas  of  consolidation.  These  lesions  are 
the  same  as  are  found  in  broncho-pneumonia.  The  temperature  curve  is  fre- 
quently the  same  as  found  in  broncho-pneumonia,  ranging  between  100°  and 
104°  F.  The  areas  of  consolidation  are  more  frequently  found  in  the  upper 
lobes.  There  is  also  broncho-vesicular  breathing  and  bronchophony.  Per- 
cussion note  shows  slight  dullness.  The  cough  may  assume  a  paroxysmal 
character  similar  to  whooping-cough.  Convulsions  and  frequently  menin- 
geal symptoms,  such  as  a  slowness  of  the  pulse  or  Cheyne-Stokes  breathing, 
will  show  the  extension  of  the  disease  to  the  brain. 

2.  Those  Assuming  a  Chronic  or  Protracted  Course. — The  duration 
of  this  form  of  the  disease  may  be  between  one  and  six  months.  Some  cases 
may  last  but  three  months.  This  is  the  most  common  type  of  the  disease 
seen.  Cases  are  frequently  seen  following  measles,  whooping-cough,  pneu- 
monia, or  diphtheria.  Those  cases  I  have  seen  ended  fatally  within  three  or 
four  months.  There  is  usually  a  slight  improvement  after  the  second  or 
third  week  of  this  disease.  The  temperature  falls  and  the  physical  signs 
seem  to  disappear.  As  a  rule  the  disease  reappears  with  more  violent  symp- 
toms, and  emaciation,  fever,  and  sweating  continue  until  the  end.  The 
temperature  curve  is  not  regular.  In  some  cases  it  ranges  between  99°  and 
101°  F.  Other  cases  will  have  a  much  higher  temperature,  the  thermometer 
registering  104°  F.  frequently.  Expectoration  is  rarely  seen  in  young 
infants  as  they  invariably  cough  and  swallow  the  same.  The  breathing 
is  usually  labored,  hence  dyspnoea  is  almost  always  present.  When  we 
have  Cheyne-Stokes  breathing,  or  irregular  breathing,  with  a  slow  pulse, 
then  cerebral  complication  should  be  suspected. 


CHAPTER  Y. 

ACUTE  TUBERCULOSIS    (MILIARY  TUBERCULOSIS).^ 

Tuberculosis  is  a  specific  infectious  disease  caused  by  invasion  of  the 
tubercle  bacillus.    The  disease  is  disseminated  by  the  same. 

Etiology. — Acute  miliary  tuberculosis  is  frequently  seen  in  very  young 
children.  I  have  seen  cases  in  bottle-fed  infants  under  1  year  of  age.  It 
is  also  frequently  associated  with  tubercular  meningitis.  As  a  rule  it  fol- 
lows those  diseases  which  devitalize  the  system,  such  as  the  acute  infec- 
tious diseases.  In  prolonged  diseases  affecting  the  air  passages,  tubercu- 
losis frequently  follows. 

Cows'  Milk. — The  majority  of  cases  of  tuberculosis  are  found  in  chil- 
dren brought  up  by  artificial  feeding.  This  implies  that  such  children 
received  cows'  milk.  The  dangers  of  infection  by  or  with  the  tubercle 
bacillus  can  usually  be  excluded  inasmuch  as  nearly  every  woman  boils  the 
milk.  The  more  modern  woman  of  to-day,  instead  of  boiling  cows'  milk, 
submits  the  food  to  a  steaming  process,  either  by  using  a  sterilizer  or  a 
pasteurizer.  The  result  is  the  same,  namely,  the  destruction  of  pathogenic 
bacteria  of  all  kind,  including  the  tubercle  bacillus.  Such  artificial  feeding 
with  cows'  milk  frequently  results  in  gastro-intestinal  derangement.  Dys- 
peptic attacks  rob  the  system  of  food  required  for  the  nutrition  of  bone, 
muscle  and  other  organic  structures.  When  such  conditions  persist  then 
poor  foundations  are  formed,  resulting  in  rickets  or  marasmus.  The  tuber- 
cle bacillus  easily  gains  entrance  where  subnormal  conditions  prevail,  and 
secures  a  foothold  that  ultimately  develops  tuberculosis. 

Woman's  Milk. — Human  milk  is  intended  by  nature  for  the  nutrition 
of  infants.  It  offers  decided  prophylactic  substances  to  the  nurslings,  for 
exajnple:  the  nursing  infant  is  very  rarely  afflicted  with  diphtheria  or 
similar  infectious  diseases.  This  is  most  probably  due  to  the  immunity 
conferred  by  human  serum  and  the  antibodies  or  bacteriolysiiis  which  the 
serum  contains  during  the  nursing  period.  This  also  accounts  for  the 
rarity  of  pulmonary  tuberculosis  in  children  reared  on  woman's  milk.  The 
value  of  human  milk  has  frequently  been  noted  by  me  while  studying  this 
question  in  a  children's  clinic  patronized  by  people  living  in  the  most  con- 
gested district  of  New  York  City. 

The  statis'tics  of  my  cases  of  tuberculosis  from  the  children's  service 
of  the  German  Poliklinik  in  New  York  City  are  very  interesting.  Five 
thousand  children  were  examined  at  random  for  the  presence  of  tubercular 


^Tuberculosis  of  the  bones,  joints,   and  glands  are  described   under  separate 
articles. 

(516) 


TUBERCULOSIS.  517 

lesions.  More  than  4900  cases  out  of  this  number  showed  no  sign  of  pul- 
monaiy  disease;  1700  of  these  cases  suffered  with  adenoids,  pharyngeal 
disease,  catarrh  of  the  naso-phar}'ngeal  tract,  or  infectious  conditions  due 
to  poor  ventilation  and  general  unsanitary  surroundings.  The  cases  were 
taken  in  children  from  the  first  to  the  tenth  year  inclusive;  59  cases  out 
of  this  whole  number  showed  distinct  evidence  of  pulmonary  tuberculosis. 
Only  9  cases  of  this  whole  number  shewed  the  presence  of  tubercle 
bacilli  in  the  sputum.  The  difficulty  in  procuring  sputum  was  an  obstacle 
in  making  more  frequent  examinations.  Forty-three  cases  of  this  number 
liad  bone  and  joint  tuberculosis  in  addition  to  evidences  in  the  lungs.  In 
two  cases  tubercular  empyema  was  found.  Five  of  these  59  cases  had 
Pott's  disease. 

Table  No.  66. — Table    showing  Blanner  of  Feeding  in  59  Consecutive  Cases  of 
Tuberculosis,  among  the  Poor. 
Planner  of  Feeding.  Xumber  of  Cases. 

Breast  milk    (human  milk) 2 

Cows'  milk   37 

Condensed  milk 18 

Modified  milk   (laboratory )     2 

Tuberculosis  in  children  is  so  closely  allied  to  scrofulosis  that  a  great 
many  authors  believe  them  to  be  identical.  There  certainly  are  a  great 
many  characteristics  common  to  both.  On  the  other  hand  a  close  scrutiny 
of  the  pathology  of  the  disease  will  show  them  to  be  distinctly  separate. 
That  scrofulosis  will  frequently  be  the  medium  through  which,  later  on, 
tuberculosis  develops,  is  well  known  and  recognized. 

"In  the  tuberculosis  of  the  new-born  evidence  shows  that  the  maternal 
ovum  may  be  infected  from  the  mother,  or  by  the  paternal  seminal  fluid; 
later  the  embryo  may  be  infected  by  the  placental  route  or  amniotic  fluid 
when  the  mother  is  tubercular.  These  modes  of  infection,  while  theoretic- 
ally possible  and  occasionally  actually  authenticated,  are  nevertheless  ex- 
tremely infrequent  in  practice.  By  whichever  of  the  above-mentioned  routes 
the  bacillus  has  gained  entrance  to  the  fcetal  organism,  there  is  no  doubt 
that  it  may  invade  it  and  remain  latent  therein  for  an  indefinite  period. 
Unless  the  bacilli  are  actually  found  within  the  tissues,  it  is  ex- 
tremely difficult  to  uphold  the  view  that  the  infection  has  not  been  acquired 
after  birth." 

The  influence  of  raw  meat  on  the  evolution  of  experimental  tubercu- 
losis has  been  described  by  Chantemesse  and  Cornil. 

Richet  and  Hericourt  published  experiments  showing  the  beneficial 
effects  of  raw  meat  in  tuberculosis  of  dogs.  Their  observations  were 
open  to  the  objection  that  the  quantity  of  meat  given  was  not  measured, 
and  that  the  good  effect  obtained  might  have  been  due  merely  to  the  fact 


518  Tiil^  INFECTIOUS  DISEASES. 

that  the  dogs  preferred  hirger  quantities  of  raw  meat  than  they  would 
have  eaten  of  boiled.  To  exclude  this  influence  the  following  experiments 
were  made.  Six  couples  of  dogs,  each  of  the  same  weight  and  appearance, 
were  taken.  One  of  each  couple  was  fed  with  boiled  meat  to  satiety,  the 
other  was  given  an  equivalent  quantity  of  raw  meat.  Both  wore  inoculated 
in  the  vein  of  the  leg  with  tuberculosis.  The  dogs  fed  with  boiled  meat 
died  at  intervals  varying  from  three  weeks  to  four  months.  The  necropsies 
showed  general  tuberculosis,  more  or  less  voluminous  caseous  granulations, 
and  advanced  fatty  degeneration  of  the  liver.  Those  fed  on  raw  meat  were 
killed  at  the  same  time.  They  were  all  plump;  they  showed  less  numerous 
tubercles  than  did  the  others,  and  less  voluminous  and  less  caseous  granu- 
lations. In  another  experiment  a  dog  was  inoculated  with  tuberculosis  and 
given  750  grams  daily  of  raw  meat.  He  preserved  his  strength,  weight,  and 
healthy  appearance.  He  was  killed  at  the  end  of  twelve  months.  The 
necropsies  showed  a  small  number  of  tubercles  in  the  viscera  and  tuber- 
cular interstitial  nephritis.  He  was  on  the  way  to  recovery.  Two  monkeys 
were  inoculated  with  tuberculosis.  One  was  fed  on  the  ordinary  diet,  and 
died  at  the  end  of  23  days  of  general  tuberculosis;  the  other  was  fed  on  raw 
meat  for  15  days  before  the  innoculation,  and  lived  for  49  days. 
Chantemesse  and  Cornil  therefore  conclude  that  the  utility  of  raw  meat 
diet  in  tuberculosis  consisted  not  in  overfeeding,  hut  in  the  anti-tubercidotts 
quality  of  the  diet. 

The  transmissibility  of  tuberculosis  by  means  of  drinking  milk  from 
cows  whose  udders  are  tuberculous,  is  admitted  by  a  great  many  authors. 

Behring  believes  that  milk  infection  remains  latent  for  years  and  then 
develops  tuberculosis.  This  he  states  accounts  for  the  absence  of  the  dis- 
ease in  very  young  infants. 

Koch  is  authority  for  the  statement  that  "bovine  tuberculosis  is  an 
entirely  different  disease  from  human  tuberculosis,  and  cannot  be  trans- 
mitted from  a  cow  to  a  It  u man  being." 

Westcnhoeffer  believes  that  caries  of  the  teeth  and  inflamed  gums,  as 
seen  during  dentition,  permit  the  invasion  of  the  tubercle  bacillus  into 
the  lymph  channels  of  the  neck,  resulting  in  cervical,  bronchial,  retrosternal, 
tracheo-bronchial,  and  finally  mesenteric  tuberculosis.^ 

Chiari,  of  Vienna,  and  Freudenthal,  of  New  York,  believe  that  the 
retropharynx  which  harbors  adenoids  is  the  point  of  entrance  of  the  tubercle 
infection.  TJiis  vieio  has  alivays  been  held  by  me,  inasmuch  as  tubercular 
meningitis  restdts  most  probably  from  an  extension  upivard  from  the 
pharynx,  and  downward,  the  infection  enters  through  the  cervical  glands. 

Contact  of  the  delicate,  perhaps  abraded,  skin  or  mucous  membrane 


'Berlin  Klin.  Woch.,  Febmary  15,  1904. 


TUBERCULOSIS.  519 

of  the  young  infant  with  tuherculous  sputum  may  result  in  inoculation,  as 
has  been  repeatedly  shown  in  connection  with  ritual  circumcision. 

The  interesting  observations  of  Lehmann  show  that  sucking  the  wound 
after  the  ritual  circumcision  of  Jewish  children  has  caused  tuberculosis. 
Baginsky  reports  a  case  of  the  transmission  of  tuberculosis  to  the  eyebrow 
of  a  child  by  a  tuberculous  person.  That  tuberculosis  may  be  transmitted 
by  the  process  of  vaccination  on  the  arm  cannot  be  disputed. 

There  must  be  a  certain  disposition  or  predisposition  to  the  develop- 
ment of  this  disease.  Other  factors  which  are  prominent  in  this  connec- 
tion are  poor  hygienic  aj)artments;  rooms  in  which  sunshine  is  absent  and 
in  which  foul  air  stagnates  will  certainly  lower  the  normal  resisting  power 
of  any  and  all  individuals.  ^Yhen  a  child  has  passed  through  an  acute 
infectious  disease  which  has  already  lowered  its  vitality,  then  an  infection 
with  tuberculosis  is  more  easily  accomplished.  Among  such  diseases  which 
predispose  to  the  development  of  tuberculosis  are  whooping-cough  and 
measles.  The  same  is  also  true  in  exhaustive  diseases  which  drain  the 
vitality  of  children  for  a  long  time,  as,  for  example,  after  a  prolonged 
attack  of  summer  complaint.  The  disease  frequently  accompanies  the 
nursing  period,  hence  even  the  youngest  child  may  become  infected. 

Tuberculosis  has  so  great  a  tendency  to  generalize  itself  in  children 
that  the  question  of  the  primary  infection  is  not  to  be  settled  by  the  mere 
frequency  of  the  lesions.  The  fact  that  children  swallow  their  sputa  is  to 
be  kept  in  mind.  There  is  no  question  as  to  its  infectiousness,  while  that 
of  infected  milk  in  the  human  species  has  not  been  absolutely  demonstrated. 
Still's  statistics  show  that  in  25  cases  taken  consecutively,  of 
children  under  3  years,  who  did  not  expectorate,  intestinal  lesions  were 
found  in  19,  while  in  a  similar  scries,  aged  between  3  and  12,  they  were 
found  in  only  10.  It  would  thus  appear  that  autoinfection  by  the  sputa  in 
infants  is  a  matter  of  serious  importance. 

Bacteriology. — The  germ  can  be  traced  to  the  blood  and  also  the  cells 
of  the  blood-vessels.  This  has  been  proven  through  studies  made  by  Dou- 
trelepont,  Lustig,  Meisels,  and  Weigert. 

Demme  found  this  specific  germ  in  pus  exuding  from  an  eczema;  the 
same  is  true  about  pus  in  otitis.  Tuberculous  affections  of  the  tongue,  of 
the  nasal  mucous  membrane,  of  the  thorax  and  tuberculous  swellings  on 
the  lips  of  young  girls  have  been  described  by  Volkmann.  Primary  tuber- 
culosis of  the  thymus,  of  the  heart,  and  of  tlie  vaginal  mucous  membrane 
have  been  published  by  Demme.  A.  Baginsky  has  described  a  series  of 
cases  of  tuberculous  ])erityphlitis,  peritonitis,  and  enteritis.  Tuberculosis 
of  the  testicles  in  children  has  been  seen  and  observed  by  him.  The  so- 
called  scrofulous  inflammatory  conditions  of  the  joints  and  suppurative  dis- 
eases of  the  bones,  while  being  described  as  "scrofulous,"  are  usually  of  a 
tuberculous  nature.     The  internal  organs  suffer  from  the  invasion  of  the 


520  THE  INFECTIOUS  DISEASES. 

tubercle  bacillus  in  this  connection.  The  lungs  and  the  pleura,  the  peri- 
cardium and  myocardium,  the  liver,  spleen,  and  kidneys,  the  coverings  of 
the  brain,  and  the  brain  itself  are  frequently  affected. 

The  question  of  the  transmission  of  the  tubercle  bacillus  is  one  that 
is  still  debatable.  Thus  Jani  reports  in  Yirchow's  Archiv,  Bd.  103,  p.  522, 
that  the  seminal  fluid  of  tuberculous  persons  contains  tubercle  bacilli.  The 
cases  of  tuljcrcles  in  the  fcctus  are  described  by  Johne  and  Armanni.^  Bang, 
Lehmann,  Birch  Hirschfeld,  Eindfleisch,  and  Kossel  are  among  those  who 
have  reported  isolated  cases  of  tul)crculosis  directly  transmitted  from 
parent  to  child.  Hochsinger  recently  reported  3  cases  which  he  describes 
as  congenital  tuberculosis.  These  cases  were  associated  with  syphilis,  and 
he  believes  that  this  disease  is  far  more  frequently  transmitted  than  is  gen- 
erally recognized.    Thus  it  appears  from  the  studies  of  Brandenberg,  Lesage, 


Fig.  1. 58.— Tubercle  Bacilli  and  Micrococcus  Tetragenus  (sputum). 
Gabbefs  stain,  Leitz  ocular  I,  oil  immersion  Vi2-  (d)  tubercle  bacilli;  (h) 
micrococcus  tetragsnus.      ( Lenliartz-Brooks ) . 

and  Wolff  that  the  placenta  is  an  exceedingly  valuable  culture  medium  for 
this  specific  micro-organism,  and  thus  they  account  for  the  com- 
parative freedom  of  the  foetus  born  to  a  tuberculous  mother. 

Cornet  and,  more  recently,  Fliigge  made  extensive  investigations  show- 
ing the  means  of  dissemination  of  the  tubercle  bacillus.  We  are  indebted 
to  them  for  our  knowledge  regarding  the  danger  of  sputum  of  a  phthisical 
patient,  and  also  regarding  the  manner  of  transmission  of  this  disease. 

How  susceptible  very  young  children  are  can  be  shown  by  a  case  pub- 
lished by  Wassermann,^  in  which  he  reports  the  transmission  of  tubercu- 
losis to  a  child  six  weeks  old  by  being  in  contact  in  the  same  room  with  a 


^  Tenth  International  Medical  Congress,  Bd.  5. 
^  Zeitschiif  t  f.  Hygiene,  p.  353. 


TUBERCULOSIS. 


521 


Fig.  159. — Tuberculosis.  Horizontal 
section  through  the  tuberculous  lower  lobe 
of  the  right  lung  of  a  two-year-old  child. 
(a)  caseous  focus  in  the  region  of  the  an- 
terior border;  (h)  nou tuberculous  poster- 
ior border;  (c)  transverse  section  of  l)ron- 
cbus;  (d.d^)  caseated  lyinph  glands;  (e) 
pulmonary  vein;  (f)  point  of  adhesion  of 
the  vein  e  with  the  lymph  gland  d';  (g) 
tubercle  in  the  lymph  vessels  of  the 
lung  parenchyma;  (h)  periarterial;  (i) 
peribronchial;  (Ic)  perivenous  tubercles;  (I)  lyni])h 
pleura;  (in)  tubercle  in  its  connective  tissue  of  the 
(Ziegler.) 


522  THE  INFECTIOUS  DISEASES. 

])litliisical  patient  for  eight  days.  Kitasato^  reports  the  fact  that  tubercle 
bacilli  (lie  rapidly  in  the  sputum,  and  he  therefore  does  not  believe  the 
danger  of  the  transmissibility  of  tubercuh)sis  is  as  great  as  has  been  claimed. 
That  contact  with  tuberculous  })atients  is  a  very  serious  matter  can  be  seen 
by  a  study  of  the  literature. 

Mother's  milk  has  been  closely  studied  and  tlie  possibility  of  infection 
Ihrough  this  channel  cannot  be  denied. 

Pathological  Anatomy. — We  are  indel)ted  to  Bayle,  Buhl,  Laiinnec,  and 
\'ircho\v  for  the  division  and  study  of  the  pathological  anatomy  of  this 
disease.  These  authors  divide  the  conditions  into  two  distinct  parts:  First, 
cheesy  pneumonia ;  second,  the  real  miliary  tuberculosis.  By  the  cheesy 
pneumonia  is  meant  that  form  of  a  chronic  destructive  process  ending  in 
cheesy  necrobiosis.  By  the  miliary  tuberculosis  is  meant  that  form  of  dis- 
ease commencing  as  a  tiny  nodular  swelling,  which  starts  in  the  connective 
tissue  and  is  associated  with  the  lymph  bodies,  having  a  tendency  to  form 
broken-down  cheesy  masses.  The  pathology  of  this  disease  can  certainly  be 
associated  with  no  greater  name  than  that  of  Yirehow,  to  whom  we  are  in- 
debted for  the  bulk  of  our  knowledge  of  this  disease. 

The  tubercle  is  a  small,  grayish-white,  translucent,  sometimes  yellowish 
body.  The  greatest  masses  consist  of  small,  round  cells  about  the  size  of 
a  red  blood-corpuscle,  and  large  cells  resembling  epithelium.  There  are 
also  giant  cells.  The  giant  cell,  as  a  rule,  can  be  found  in  the  middle  of 
these  tubercles  and  is  so  closely  identified  with  this  condition  that  it  has 
been  looked  iipon  as  characteristic  of  this  disease. 

The  growth  of  the  tubercle  consists  in  the  development  of  new  masses 
arising  from  the  giant  cells.  In  these  giant  cells  there  are  no  blood-vessels, 
and  as  there  is  no  nutrition  they  easily  break  down  and  form  what  is  later 
on  the  beginning  of  cheesy  masses,  which,  by  absorption  and  a  melting 
process,  are  the  real  beginnings  of  cavities.  At  times  these  masses  result  in 
chalk  deposits.  The  question  of  the  specific  origin  of  the  disease  has  been 
finally  settled  by  the  investigations  of  Koch,  who  proved  the  specific  micro- 
organism known  as  the  tubercle  bacillus  to  be  the  pathological  factor. 

Biedert  found  IG  cases  of  primary  intestinal  tuberculosis  among  3104 
post-mortems. 

Heller  found  7.4  per  cent,  of  primary  tuberculosis  among  714  post- 
mortems in  diphtheria,  and  a  total  of  19.6  per  cent,  of  all  varieties  of 
tuberculosis  among  these  714  cases. 

Orth  states  that  primary  intestinal  tuberculosis  is  exceedingly  rare  in 
Berlin  because  of  the  universal  use  of  sterilized  or  boiled  milk.^ 


'Zeitschr.  f.  Hygieno,  P.d.  9,  1892,  Heft  3. 

"  I  liave  collected  and  described  a  series  of  important  observations  on  the 
association  of  cows'  milk  with  tuberculosis.  The  patholofjy  of  the  cow's  udder  and 
the  milk  ducts  are  also  described.      (See  chapter  on  "Cows'  Milk.") 


TUBERCULOSIS. 


523 


Baginsky  reports  that  he  foimd  8  cases  of  tuberculosis  that  died  among 
871  nurslings  at  his  Berlin  hospital.  These  were  all  under  ten  months  of 
age.  On  the  other  hand  he  found,  among  2G6  children  in  the  second  year, 
13  died  of  miliary  tuberculos's.  One  hundred  and  eighty-two  children  out 
of  611  died  of  miliary  tuberculosis  between  the  age  of  2  and  -4  years.  Out 
of  152  children  examined  between  the  age  of  4  and  6  years,  6  had  miliary 
tul)erculosis. 


Fig.  IGO. — Acute  Pulmonary  Miliary  Tuberiulosis  (Cut  Surface  of  the 
Lung.)  (a)  so-called  obsolete  tubercle  (old  encapsulated  caseous  focus),  (h) 
induration,  (c)  caseous,  partly  agniinatetl  nodules  (transverse  section  of 
caseous  bronchi.)  (0)  subiniliary  noneaseated  tubercle  in  tlie  true  lung 
tissue.  (('.)  tubercle  of  the  pulmonary  pleura.  One  half  natural  size.  (Lang- 
erhans.) 


Still'  considers  lliese  facts  aiul  olfers  some  interesting  .statistics,  based, 
not  on  clinical  ol)servation,  but  on  post-mortem  findings,  for  the  solution 
of  this  problem.  Tn  709  autopsies  of  children,  tubercle  was  found  in  269, 
or  35.2  per  c(>nt.  TulxTculosis  was  the  actual  cause  of  deaths  in  2.")2.  or  32.8 
per  cent.     From  these  statistics,  therefore,  it  can  be  roughly  estimated  that 


Clinical   .loiniial.    I.ninlon. 


524 


THE  INFECTIOUS  DISEASES. 


about  one-third  of  the  deaths  in  chiklhood  are  due  to  tuberculosis  in  one 
form  or  other.  While  children  are  thus  shown  to  be  specially  subject  to 
this  disease,  they  are  not  equally  so  at  all  ages,  for  Still  shows  that  up  to  the 
age  of  4  the  ])ercentage  is  as  high  as  71,  and  between  4  and  8  is  still  22.5; 
after  8  it  diminishes  to  6.5.  Moreover,  the  greater  part  of  the  tuberculosis 
under  the  age  of  4 — A'.iA  of  the  Tl  per  cent. — occurred  in  children  under 
2  years  of  age.  This  great  frequency  of  tuberculosis  in  infancy  has  been 
used  as  an  argument  in  favor  of  the  idea  of  infection  through  milk,  the 
j)rinuiry  lesion  l)eing  in  the  digestive  tract.  It  is  true.  Still  says,  that  in- 
testinal tuberculosis  is  exceedingly  common  in  children;  it  existed  in  52 
per  cent,  of  his  cases  examined,  but  so  also  is  that  of  the  brain  and  meninges 
— 48  per  cent. — and  that  of  the  lungs  is  far  more  frequent — 78  per  cent. 

Table  No.  67. — Deaths  frvn  Phthisis  Palmonalis  [Pulmonary  Tuberculosis)  in 
Children  Under  15  Years  in  Old  New  York  City. 


Total 

0 
Years. 

1 

Year. 

2 
Years. 

3 
Years. 

4 
Years. 

Total 

Under 

5  Years. 

5 
Years 

10 
Years. 

1890 

Males 
Females 

98 
145 

30 
31 

24 
23 

10 
12 

5 

7 

7 
2 

76 
75 

14 
25 

8 
45 

1891 

Males          .    . 
Females      .    . 

91 
119 

27 
25 

15 
16 

7 
9 

7 
3 

5 
4 

61 

57 

13 
16 

17 
46 

1892 

Males          .    . 
Females 

109 
114 

33 
29 

29 

21 

15 
10 

6 

8 

3 
5 

85 
73 

17 
22 

39 

1893 

Males      .    .    . 
Females 

119 

14) 

31 
29 

27 
17 

8 
11 

10 

7 

8 
9 

84 
73 

14 
20 

21 
47 

1894 

Males 
Females 

108 
102 

31 
20 

18 
15 

10 
10 

8 

7 

6 
3 

73 

55 

20 

12 

15 
35 

1895 

Males  .    . 
Females 

117 
122 

45 
26 

29 

27 

12 
6 

5 

7 

5 
3 

96 
69 

6 

18 

15 
35 

1896 

Males 
Femaes 

87 
113 

24 

21 

26 
15 

7 
13 

5 
5 

1 
3 

63 

57 

14 

18 

10 
38 

1897 

Males 
Females 

93 

104 

28 
23 

24 

17 

8 

7 

3 
6 

3 
10 

65 
63 

11 
14 

17 

27 

1898 

Males 
Females 

84 
92 

29 
13 

18 
12 

4 
9 

3 
5 

2 

5 

56 
44 

14 
17 

14 
31 

1899 

Males         .    . 
Females 

110 
117 

37 

28 

16 
13 

10 
12 

9 

10 

5 
4 

77 
67 

11 
17 

22 
33 

1900 

Males         .    . 
Females      .    . 

108 

87 

28 
11 

23 

10 

16 
6 

8 

7 

5 
5 

79 
39 

13 
22 

16 
26 

1901 

Males      .    .    . 
Females 

94 
106 

25 

18 

19 

17 

8 

7 

7 
4 

5 

7 

64 
53 

16 
12 

14 
41 

Total  for  10  Years,  2579 


TUBERCULOSIS. 


525 


The  total  number  of  deaths  reported  as  due  to  consumption  in  the 
United  States  during  the  census  year,  was  109,750,  of  which  53,626  were 
males,  and  56,124  were  females;  and  the  ratio  of  deaths  from  this  disease 
to  1000  deaths  from  all  known  causes  was  109.9.  In  1890  the  correspond- 
ing ratio  was  122.3. 

The  death  rate  of  the  colored  from  consumption  was  nearly  three  times 
that  of  the  whites,  and  that  of  the  foreign  whites  was  .much  higher  than 
that  of  the  native  whites.  For  tlie  last-mentioned  class  the  death  rate  for 
those  having  one  or  both  parents  foreign,  was  also  much  higher  than  for 
those  of  native  parents. 

The  death  rate  of  males  from  this  disease  was  considerably  higher  than 
those  of  females. 

The  total  number  of  deaths  reported  as  due  to  consumption  in  the 
United  States  in  children  under  15  years  of  age,  during  the  census  years 
1890-1900,  was  8051,  of  which  3554  were  males,  and  4497  were  females. 


Table  No.  68. 


Registration  States. 

Total. 

Cities. 

Rural. 

19"0 
Connecticut                   ...       -laoc) 

168.3 
233  6 

183.7 
272  6 

141.8 
205.8 

District  of  Columbia      ....  jqqq 

305.3 
359.0 

.305.3 
359.0 

nj  ■                                                      1900 
Maine                                             jggo 

164.9 

191.7 

159.4 

Massachusetts        hqq„ 

186.2 
267.1 

193.7 
279.4 

162.5 
227.0 

Michigan 1900 

100.7 

116  7 

91.1 

tr           u-                                     1900 
New  Hampshire            .    .              jgo^ 

152.3 
1936 

176.2 
191.9 

137  3 
194.3 

T                                               1900 
New  Jersey    .   .                           jggy 

180.1 
234.5 

194.1 
247.7 

202.2 
268.9 

151.1 
189.4 

New  York      J^OO 

221.4 
306.6 

137.3 
152.3 

Rhode  Island                                jggj] 

195.3 
266.6 

208.3 
294.9 

170.0 
227.6 

^           ,                                         1900 
^^■■""^"* 1890 

l.'i2.5 
198.8 

160.9 
2439 

151.2 
194.7 

T«.^ai                                     1900 
T°*'^^       1890 

175.9 
249.0 

204.8 
293  5 

134.1 
IRl.O 

This  tabic  sl'.ows  thai  tlic  ilcatli  I'atc  rrnm  consumption  in  the  registra- 
tion States  was  higher  in  the;  District  of  Columl)ia  (305.3),  whicli  was  due 


526 


THE  INFECTIOUS  DISEASES. 


mainly  to  the  large  colored  population.  The  next  highest  rate  in  the  regis- 
tration States  was  in  Khode  Island,  where  it  was  195.3.  The  death  rate 
from  this  disease  was  higher  among  males  than  females  in  the  cities,  but 
lower  in  the  rural  districts.  Excluding  the  District  of  Columbia,  the  high- 
est occurred  among  males  in  the  city  of  Xcav  York  (265.3),  and  the  lowest 
among  males  in  the  rural  districts  of  Michigan. 

The  following  table  shows  that  the  death  rates  due  to  consumption  in 
white  persons  under  15  years  of  age  were  highest  in  those  whose  mothers 
were  born  in  Italy  (50.7),  in  France  (47.1),  and  in  "other  foreign"  coun- 
tries (45.9)  ;  and  were  lowest  in  those  whose  mothers  were  born  in  Poland 
(11.-4),  in  Bohemia   (13.3),  and  in  Germany   (36.6). 


Table  No.  69. 


Color  and  Birthplaces  of  Mothers. 


Under  1.5  Years. 


White . 

Colored        • 

Mothers  born  in — 
United  States     .    . 
Ireland 
Germany 

England  and  Wales 
Canada  -    .    . 

Scandinavia    .    ,    . 

Scotland 

Italy 

France     

Hungary 

Bohemia 

Russia 

Poland 

Other  foreign      .    . 


31.8 
246.0 


27.0 
42.2 
26.6 
27.2 
345 
32.4 
32.9 
50.7 
47.1 
38.6 
13.2 
26.7 
11.4 
45.9 


Table  No.   70. — Percentage  of  Death>i  per  lOGO  from  Cotistimjition  in  C  hildren  from 
1  to  15  years  of  age.    (  United  States). 


Age. 


Under  1  year  , 

1  year       .    .    . 

2  years     .    .    . 

3  years .        .    . 

4  years . 
Under  5  years 

5  to  9  yeara 
10  to  14  years  . 


Males. 


18.8 
9.3 
5.2 
3.3 
2.3 

38.9 
8.1 


Females. 


17  8 
9.6 

4.8 

4.0 

2.2 

38.4 

13.2 

24.7 


Males. 


20.1 
9.7 

5.1 

2.7 
2.0 

39.6 
8.1 

10.7 


IS'JO 


16.5 

10.9 

5.0 

3.6 

28 
38.8 
11.7 
27.2 


TUBERCULOSIS. 


527 


Table  No.   71. — Deaths  from  Other    Tabercitlar    Diseases  in  Children  Under  15 
Years. — New  York  Cit-<. 


0 

1 

2 

3 

4 

Tota 
Under 
5  Years. 

5  to  10 

10  to 

15 
Yrs. 

Total 
Under 

Year. 

Yr. 

Yrs. 

Yrs. 

Yrs. 

Years . 

15 
Years. 

Tabes  Mesenterica 

17 

4 

. 

1 

22 

22 

1890 

Taber.  Meuingitis 

132  • 

79 

31 

23 

13 

278 

24 

8 

310 

Other  Forms    .    . 

52 

10 

6 

1 

2 

71 

2 

2 

75 

Males 

Spinal        ... 

2 

1 

1 

4 

4 

3 

11 

Hip. 

1 

1 

1 

1 

3 

Tabes  Mesenterica 

9 

2 

1 

■  .■ 

12 

3 

15 

Tuber.  Meningitis 

92 

70 

33 

19, 

8 

222 

20 

4 

246 

Females 

Other  Forms 

37 

18 

10 

3 

3 

71 

4 

75 

Spinal 

2 

3 

5 

4 

1 

10 

Hip. 

2 

1 

3 

3 

1 

7 

Tabes  Mesenterica 

16 

3 

1 

1 

21 

1 

22 

1891 

Tuber.  Meningitis  . 

118 

88 

26 

19 

12 

£63 

24 

8 

295 

Other  Forms     .    . 

30 

21 

4 

3 

3 

61 

5 

5 

71 

Males 

Spinal        .... 

1 

1 

3 

5 

9 

Hip 

2 

2 

4 

5 

3 

12 

Tabes  INIesenterica 

11 

4 

15 

1 

16 

Tuber.  Meuingitis 

123 

75 

29 

23 

11 

261 

24 

3 

288 

Females 

Other  Forms    .    .    . 

35 

12 

5 

3 

2 

57 

7 

3 

67 

Spinal 

1 

1 

4 

3 

8 

Hip 

1 

1 

10 
1 

11 

Tabes  Mesenterica 

12 

4 

1 

17 

18 

1892 

Tuber.  Meningitis 

148 

90 

28 

14 

19 

299 

23 

8 

330 

Other  Forms    .    . 

42 

25 

5 

5 

3 

80 

4 

1 

85 

Males 

Spinal 

1 

1 

1 

1 

4 

3 

4 

11 

Hip 

1 

1 

1 

3 

2 

4 

9 

Tabes  Mesenteric! 

16 

2 

2 

20 

1 

21 

Tuber.  Meningitis 

115 

61 

37 

19 

10 

242 

27 

6 

275 

Females 

Other  Forms 

36 

19 

5 

1 

2 

63 

6 

3 

72 

Spinal    ..... 

1 

1 

2 

3 

4 

9 

Hip 

1 

1 

3 

1 

5 

Tabes  Mesenterica 

18 

2 

1 

21 

1 

22 

1893 

Tuber.  Meningitis 

157 

80 

35 

23 

14 

309 

24 

7 

840 

Other  Forms    .    . 

32 

14 

9 

1 

2 

58 

8 

4 

70 

Males 

Spinal 

1 

3 

1 

2 

7 

7 

3 

17 

Hip 

1 

1 

4 

2 

7 

Tabes  Mesenterica 

16 

2 

18 

18 

Tuber.  Meningitis 

114 

59 

25 

19 

16 

233 

30 

4 

267 

Females 

Other  Forms    .    . 

36 

16 

8 

2 

62 

6 

5 

73 

Spinal        

1 

1 

5 

2 

8 

Hip 

1 

1 

1 

1 

Tabes  Mesenterica 

11 

5 

3 

19 

19 

1894 

Tuber    Meningitis 

143 

87 

27 

20 

18 

295 

35 

5 

335 

Other  Forms 

25 

13 

3 

5 

46 

9 

4 

59 

Males 

Spinal        .        .    . 

1 

2 

3 

1 

1 

8 

4 

3 

15 

Hip        

1 

1 

2 

3 

4 

9 

Tabes  Mesenterica 

i 

4 

1 

12 

1 

13 

Tuber.  Meningitis 

102 

62 

37 

19 

7 

227 

28 

« 

263 

Females 

Otlier  Forms 
Spinal                .    . 

27 

11 

4 

4 

1 

6 

52 

1 

13 
2 

10 
3 

75 
6 

Hip        

1 

1 

2 

5 

1 

8 

528 


THE  INFECTIOUS  DISEASES. 


Table  No.  71. — Deaths  from  Other  Tiiberculnr  Diseases  in  Children  Under  15 
Years. — Neio  York  City. — [Coniimted). 


0 
Year. 

1 

Yr. 

2 
Yrs. 

I! 
Yrs. 

4 
Yrs. 

Total 
Under 
5  Years 

5  fo  10 
Years. 

10  to 

15 
Yrs. 

Total 

Under 

1.5 

Years. 

Tabes  Mesenterica 

12 

1 

• 

13 

1 

14 

1895 

Tuber.  Meningitis 

147 

73 

38 

15 

17 

290 

17 

9 

316 

Other  Forms    .    .    . 

47 

15 

8 

2 

1 

73 

8 

3 

84 

Males 

Spinal            .... 
Hip        

1 

1 

2 

1 

1 
1 

0 
0 

5 
3 

8 

18 
5 

Tabes  Mesenterica 

9 

1 

1 

1 

12 

13 

Tuber.  Meningitis 

94 

61 

44 

25 

12 

236 

26 

7 

269 

Females 

Other  Forms    .    .    . 

3C 

15 

2 

3 

3 

59 

9 

1 

69 

Spinal        .... 

1 

3 

3 

7 

5 

1 

13 

Hip 

3 

1 

4 

2 

4 

10 

Tabes  Mesenterica  . 

9 

1 

1 

11 

11 

189G 

Tuber.  Meningitis 

103 

75 

38 

15 

22 

252 

22 

8 

282 

Other  Forms    .    .    . 

47 

17 

6 

3 

6 

79 

11 

7 

97 

Males 

Spinal            .... 

1 

9, 

3 

6 

5 

11 

Hip 

1 

1 

1 

3 

3 

2 

8 

Tabes  Mesenterica  . 

11 

4 

2 

17 

1 

18 

Tuber.  Meningitis  . 

85 

59 

25 

18 

15 

202 

23 

4 

229 

Females 

Other  Forms        .    . 

26 

14 

6 

7 

4 

57 

11 

11 

79 

Spinal 

2 

1 

1 

4 

3 

1 

8 

Hip    .    .        ... 

3 

1 

4 

Tabes  Mesenterica  . 

10 

1 

11 

1 

13 

1897 

Tuber.  Meningitis 

114 

73 

34 

21 

11 

253 

23 

4 

380 

Other  Forms        .    • 

38 

14 

10 

5 

2 

69 

11 

11 

91 

Males 

Spinal 

1 

1 

2 

4 

0 

4 

13 

Hip        

1 

1 

3 

1 

5 

Ta])es  Mesenterica  . 

3 

1 

4 

4 

Tuber.  Meningitis  . 

102 

00 

20 

15 

12 

209 

24 

4 

237 

Females 

Other  Forms    .    .    • 

38 

17 

8 

4 

4 

71 

12 

4 

87 

Spinal 

2 

1 

3 

0 

4 

9 

Hip            

1 

1 

2 

2 

Tabes  Mesenterica  . 

7 

7 

1 

8 

1898 

Tuber.  Meningitis  . 

113 

87 

33 

24 

14 

271 

26 

3 

300 

Other  Forms    .    .    . 

25 

23 

5 

2 

3 

58 

7 

4 

69 

0, 

1 

1 

4 

2 

6 

Hip    ......    . 

2 

1 

3 

Tabes  Mesenterica  . 

10 

2 

1 

13 

13 

Tuber.  Meningitis  . 

91 

68 

18 

19 

14 

210 

23 

7 

240 

Females 

Other  Forms    .    .    . 

32 

9 

8 

2 

1 

52 

5 

6 

63 

Spinal 

1 

1 

2 

2 

4 

Hip 

•    • 

1 

1 

2 

1 

3 

Tabes  Mesenterica 

7 

2 

9 

9 

1899 

Tuber.  Meaingitis 

107 

70 

38 

19 

12 

240 

18 

7 

271 

Other  Forms    .    .    . 

13 

11 

10 

7 

3 

44 

8 

3 

55 

Males 

Spinal 

Hip        .            ... 

1 

1 

2 

1 

3 

5 
2 

Tabes  Mesenterica  . 

5 

1 

1 

7 

7 

Tuber.  Meningitis 

90 

69 

27 

21 

16 

229 

27 

5 

261 

Females 

Other  Forms 

26 

15 

5 

5 

3 

54 

14 

12 

80 

Spinal        .... 

1 

.    . 

1 

2 

4 

1 

7 

Hip 

1 

!  ■    • 

1 

2 

1 

4 

TUBERCULOSIS. 


529 


Table  No.  71. — Deaths  from  Other  Tubercular  Diseases  in  Children  Under  15 
Years. — New  York  City. — {Continued). 


0 
Year. 

1           2 
Yr.      Yrs. 

3 
Yrs. 

4 
Yi-s. 

Total 
Under 
5  Years. 

5  to  10 
Years. 

10  to 

15 
Yrs. 

Total 
Under 

15 
Years. 

1900 
Males 

Females 

Tabes  Mesenterica 
Tuber.  Meningitis  . 
Other  Forms    .    .    . 

Spinal 

Hip    ...    . 
Tabes  Mesenterica 
Tuber.  Meningitis 
Other  Forms    .    .    . 

Spinal 

Hip 

7 
97 
20 

2 

5 
96 

18 

96 
13 

4 

8 

79 
9 

6 

o 

82 
8 
1 

3 
59 

7 

1 

1 
43 

7 

24 
4 

21 
4 

22 

1 

12 

'  1 

1 

1 

20 
1 
1 

1 
1 

10 
4 

11 
2 

1 

10 

253 

43 

3 

. 

8 

212 

32 

1 

1 

27 
13 

5 

30 

4 

o 
2 

'  8 
9 
4 

10 

10 

1 

1 

10 

288 

65 

7 

5 

8 

252 

46 

4 

4 

1901 

Tuber.  Meningitis  . 
Abdominal  Tuber. 
Pott's  Disease  .    .    . 
Cold  Abscess    .    . 
White  Swellinii; 
Tuber,  of  Other  Org. 
General  Tuber.    .    . 

Tuber.  Meningitis  . 
Abdominal  Tuber. 
Pott's  Disease  .    .    . 
White  Swelling 
Tuber,  of  Other  Org 
General  Tuber. 

59 
5 
1 
1 

5 

48 

'  2 
2 

28 
3 

t 
5 

29 

1 

5 

13 

1 

\ 

8 

'  1 
1 
1 
1 

208 

22 

3 

1 

6 
19 

184 

11 

2 

1 

4 

15 

25 
4 

6 
3 

239 

29 

3 

Males 
Females 

3 
9 

7 

24 
2 
2 
2 
4 
2 

1 
6 
1 

10 
3 

2 
4 

1 

b 

21 

27- 

218 

16 

4 

2 

10 
21 

J.  "Walker  Carr  reports  statistics  of  necropsies  on  tuberculous 
children  at  the  Victoria  Hospital.  He  found  79  in  which  the  disease  most 
probably  started  in  the  chest,  and  20  in  which  it  seemed  to  have  begun  in 
the  abdomen.  Here  the  relation  between  the  two  forms  of  infection  is  as 
1  to  4.  In  2G  children  of  early  or  limited  tuberculosis,  the  thorax  alone 
was  affected  in  12  cases,  the  abdomen  in  7,  being  in  the  proportion  of  1  to 
1.7.  Of  53  tuberculous  children  under  2  years  of  age  the  disease  most 
probably  began  in  the  chest  in  43  and  in  only  5  certainly  in  the  abdomeu, 
the  proportion  in  this  case  being  as  1  to  8.6.  Out  of  27  children  over  5 
years  of  age,  the  disease  began  in  the  chest  in  12,  in  the  abdomen  in  G,  the 
relation  .being  as  1  to  2. 

These  statistics  being  all  from  English  sources  are  fairly  comparable, 
and  it  appears  to  me  they  sustain  Thome's  contention  that  the  returns 
in  England  of  tabes  mesenterica  represent  with  fair  accuracy  the  abdominal 
tulx'rculosis  of  children. 

Bollinger,  in  his  address  at  the  International  Tuberculosis  Congress, 
of  Berlin,  in  1899,  quoted  with  ajiproval  the  record  of  autopsies  by  Heller 
(Kiel  )of  248  tuberculous  children.  In  45.5  per  cent,  of  the  cases,  tuber- 
culosis  involved   the   mesenteric   glands.     From    these   it   was    concluded 

34 


530  THE  TXFFX'TTOl'S  DISEASES. 

that  milk  played  a  loadinf,^  role  in  the  so-called  iransmitted  tuberculosis  of 
children. 

It  is  plain  i'roni  what  has  been  said,  without  (juotiiig"  further  statistics, 
that  iu  some  countries  where  bovine  tuberculosis  is  very  frequent,  there  is 
also  a  great  frequency  of  tuberculosis  in  cliildren.  Bollinger  concludes  that 
"although  the  tuberculosis  of  cattle  and  swine  does  not  stand  in  the  first 
line  as  source  and  starting  point  of  human  tuberculosis,  nevertheless — con- 
sidering their  enormous  distribution  and  progressive  additions,  and  the  great 
danger  from  the  ingestion  of  the  milk  of  tuberculous  cows — they  are  cer- 
tainly for  humanity  the  most  important  and  the  most  dangerous  of  all 
animal  plagues,  and  deserve  the  most  earnest  attent'on  from  the  sanitarian 
and  the  state." 

Symptoms. — The  more  important  symptoms  noted  in  this  condition  are 
a  general  restlessness  wnth  a  rise  of  temperature.  Children  frequently  have 
little  or  no  cough,  but  some  difficulty  with  respiration  for  which  no  distinct 
physical  signs  can  be  found.  The  temperature  will  sometimes  rise  as  high 
as  103°  or  104°  F.,  or  it  may  suddenly  become  apyretic  and  assume  a  sul)- 
normal  tendency.  The  temperature  usually  seen  is  101°  F.  The  children 
appear  very  anaemic  and  at  times  cyanotic,  mostly  on  the  cheeks  and  lips. 
Emaciation  usually  accompanies  this  "intermittent  type  of  fever."  To  the 
inexperienced,  the  beginning  of  a  miliary  tuberculosis  resembles  mostly  the 
clinical  picture  which  so  frequently  accompanies  intermittent  fever.  There 
usually  is  slight  swelling  of  the  peripheral  lymph  glands.  The  spleen  and 
liver  will  be  felt  enlarged.  The  urine  will  give  a  slight  diazo  reaction,  also 
an  indican  reaction.  Neither  of  these,  however,  are  constantly  present.  We 
have  what  is  commonly  known  as  a  "pre-tubercular  ansemia,"  in  which  there 
is  a  general  tendency  to  hreal-down,  and  pallor  so  well  marked,  for  which 
there  is  no  distinct  group  of  symptoms.  When  such  profound  anaemia 
exists  with  slight  variations  of  temperature,  then  tuberculosis  may  be  in- 
ferred; hence  this  stage  is  regarded  by  some  clinicians  as  the  "pre-tuber- 
cular"  stage.  Occasionally  the  examination  of  the  chest  shows  catarrhal 
symptoms  and  rhonchi  as  accompany  an  ordinary  bronchitis.  There  is  an 
absence  of  bronchial  breathing  and  no  distinct  evidence  of  dullness  on  per- 
cussion. Frequently  these  symptoms  increase  in  severity.  Cyanosis  may 
accompany  this  condition  and  the  circulation  may  l)e  so  poor  as  to  show  cold 
feet  and  hands.  Death  occasionally  follows  this  condition.  The  clinical 
picture  here  given  is  the  one  that  is  frequently  seen  in  that  type  of  acute 
miliary  tuberculosis  running  a  malignant  and  very  short  course.  In  this 
condition  the  children  appear  very  pale  and  lose  weight.  There  is  distinct 
anorexia  which  alternates  with  h3^perorexia.  Dyspeptic  symptoms,  such  as 
vomiting  and  diarrhoea,  may  alternate  with  constipation.  Such  children 
are  usually  very  sensitive  and  inclined  to  be  peevish  and  cry  on  the  slightest 
provocation. 


TUBERCULOSIS.  531 

A  study  of  the  above  symptoms  will  show  that  there  are  no  distinct 
typical  symptoms  which  can  be  laid  down  as  positively  diagnostic.  It  is 
for  this  reason  that  so  many  other  diseases  are  confounded  with  miliary 
tuberculosis  until  the  same  has  progressed  considerably.  When  there  is 
marked  cachexia  accompanying  nurslings  for  which  there  is  no  distinct 
reason,  and  especially  so  if  the  fever  accompanying  the  same  is  an  inter- 
mittent type,  then  we  should  not  forget  the  possibility  of  our  dealing  with  a 
case  of  miliary  tuberculosis. 

Case  I.  A  child,  2  years  old,  was  brought  to  my  children's  clinic  at  the  New 
York  Post-Graduate  Medical  School  and  Hospital,  with  the  following  historj':  She 
was  a  bottle-fed  infant  raised  on  condensed  milk.  The  bowels  were  always  con- 
stipated. Has  had  one  attack  of  cholera  infantum  when  eleven  months  old  which 
caused  emaciation  and  general  atrophy. 

Present  illness  dates  back  to  three  months  ago  wlien  child  had  measles  fol- 
lowed by  a  severe  broncho-pneumonia.  The  cough  has  persisted,  but  mostly  at 
night.      There  was  no  expectoration. 

Physical  Examination. — Examination  reveals  an  emaciated,  very  rachitic  child, 
pigeon-breasted,  with  decided  beaded  ribs.  There  is  also  a  kyphosis.  The  abdomen 
is  distended  (pot-belly).  The  superficial  veins  are  enlarged,  the  head  show>? 
marked  frontal,  parietal,  and  occipital  rickets.  Cranio-tabes  is  also  present,  so 
that  we  can  safely  call  this  a  markedly  rachitic  case.  At  the  left  apex  there  were 
heard  coarse,  mucous  and  sonorous  rales,  also  prolonged  expiration.  The  right  lower 
lobe  had  several  areas  of  amphoric  breathing,  also  some  friction  sounds  and  prolonged 
harsh  expiration.  Percussion  note  was  dull.  The  morning  temperature  in  the  rectum 
was  101°  F.,  pulse  144,  respiration  40.  The  a2>petite  was  poor,  spleen  enlarged,  hands 
and  feet  cold,  and  the  child  perspireil  freely. 

Diagnosis. — Tuberculosis  after  morbilli. 

Family  History. — The  father  died  of  tuberculosis  when  the  infant  was  six 
months  old.  The  mother  is  still  living  and  in  apparent  good  health.  Two  other 
children  in  the  same  family  show  no  evidence  of  illness.  The  family  live  in  a 
rear  house  behind  a  tenement  house.  The  weight  of  the  cliihl  when  first  seen  was 
sixteen    pounds. 

Treatment. — An  emulsion  of  the  yolks  of  G  eggs  containing  sugar,  and  15  drops  of 
creosote  carbonate  was  fed  each  day.  Buttermilk  and  the  serum  of  bullock's  blood 
was  given  in  wineglassful  doses  several  times  a  day.  The  child  was  .S!ent  to  the 
country  and  ordered  to  live  out  of  doors.  The  appetite  improved  and  the  congh 
lessened.  From  month  to  month  the  clinical  symptoms  gradually  subsided  and 
at  the  end  of  two  years  the  physical  signs  in  the  lungs  entirely  disappeared,  and  her 
weight  increased  to  32  pounds. 

In  this  case  tubercle  bacilli  were  found  in  the  sputum  that  was  vomited  after  a 
severe  coughing  paroxysm.    Tlie  case  is  well  to-day. 

Case  it.  A  girl,  12  years  old,  seen  by  me  some  years  ago,  was  brought  to  my 
children's  clinic  at  the  New  York  Post-Craduate  Me<Iical  School  and  Hospital.  She 
was  suffering  with  headache,  cough,  general  malaise,  poor  appetite,  and  emaciation. 
She  had  been  under  the  treatment  of  a  physician  who  diagnosed  malaria.  The 
bowels  were  irregular,  at  times  constipated,  at  other  times  diarrlia>al.  Tlie  urine, 
light  amber  color,  contained  nothing  abnomial.  The  child  perspired  freely  at  the 
slightest  exertion,  even  after  each  paroxysm  of  cough. 

Previous  History. — She   was   a   bottle-fed    iufaiif.       Had    measles   and   broncho- 


532  'i'tlE  INFECTIOUS  DISEASES. 

pneumonia  at  3  years.  When  5  years  old  had  had  whooping-cough  which  histed 
four  months.      Excepting  an  occasional  cough  no  other  symptoms  were  present. 

FaniUij  Hlstiiry. — The  family  history  is  good.  Both  parents  are  living  and 
four  brothers;  all  are  healthy.  The  only  history  as  to  etiology  is  that  this  girl 
has  lived  in  luisanilary  surroundings,  besides  having  a  weakened  state  of  the 
respiratory  tract. 

Physical  Ed-aniiiKitioii. — At  the  lirst  examination  she  appeared  slightly  icteric, 
the  spleen  was  enlarged,  the  liver  normal.  There  was  a  slight  didlness  at  the 
apex  of  the  right  side,  some  mucous  rales  and  harsh  breathing.  There  was  a  slight 
expectoration,  no  history  of  haemoptysis.  Nose  bleeding  was  complained  of  occa- 
sionally. The  diagnosis  was  made  by  tlie  presence  of  tubercle  bacilli  in  the 
sputiun.  Each  month  her  sputum  was  examinedj  and  it  was  found  that  the 
sputum  which  was  exjjectorated  during  the  early  morning  hours,  between  4  and  (5 
A.M.,  contained  the  greatest  number  of  tubercle  bacilli.  After  four  months  of  treat- 
ment it  was  found  that  the  bacilli  in  the  morning  sputum  were  so  sparingly  present 
that  evidently  some  change  was  going  on.  The  symptoms  of  headache  and  malaise 
disappeareil  entireh".  The  icteric  condition  disappeared.  The  epistaxis  has  not 
shown  itself  within  the  last  five  months.  A  careful  examination  of  the  sputum 
four  times  a  month  has  not  shown  a  single  tubercle  bacillus. 

The  treatment  consisted  in  removing  the  child  from  school  and  giving  her  a 
•substantial  diet  of  Avhich  proteids  formed  the  chief  part.  The  hygienic  conditions 
were  improved  as  much  as  the  circumstances  of  the  family  would  permit. 

I  impressed  the  family  with  the  necessity  of  removing  the  child  to  the  country 
and  she  was  given  into  the  employ  of  a  farmer,  and  ordered  to  be  in  the  open  air 
all  of  the  time.  Six  months  later  I  saw  the  case  again.  She  had  gained  in  weight. 
Her  cough  had  ceased  and  the  physical  signs  were  lessened. 

The  child  lived  in  the  country  eighteen  months. 

At  the  end  of  this  time  there  was  no  evidence  of  cough  nor  of  the  general 
malaise  excepting  the  physieal  signs  on  auscultation  and  percussion.  I  have  seen 
this  child  in  all  about  seven  years  and  believe  that  she  is  quite  healthy.  The 
pulmonary  symptoms  have  entirely  disappeared. 

According  to  Loomis,  tuberculosis  and  cavities  in  the  lungs  can  and  do  heal. 
I  have  good  reason  to  believe  that  in  this  patient,  in  whom  we  diagnosed  apex  tuber- 
culosis or  a  catanhal  tuberculosis  afl'ecting  the  apices  of  both  lungs,  this  proce-iS 
was  arrested  in  its  incipiency. 

Diagnosis. — Method  of  Ohtoining  Sputum:  In  infants  and  yonng  chil- 
(ii'cn  who  do  not  expectorate,  the  following  method  of  obtaining  sputum  is 
{Suggested  by  Findlay,  of  Glasgow:  "With  a  piece  of  ganze  on  the  fore- 
finger, the  pharynx,  and  especially  the  epiglottis,  is  irritated  so  as  to  induce 
coughing,  and  any  expectoration  that  is  coughed  up  is  swept  out  of  the 
mouth  before  it  has  time  to  be  swallowed.  The  quantity  thus  ol)tained 
varies,  but  as  a  rule  is  sufficient  for  bacteriological  examination." 

The  diagnosis  will  fre([uently  l)e  very  difficult,  especially  so  if  no  data 
can  be  obtained  which  will  complete  our  clinical  picture.  If  the  child 
has  been  exposed  to  tuberculous  individuals  then  a  suspicion  may  arise  (if 
there  is  a  tuberculous  family  disposition)  of  a  possibility  of  the  development 
of  this  disease.    Frequently  the  symptoms  arc  such  as  to  resemble  typhoid. 


PLATE  XIV 


Old  Tuberculin, 
Undiluted 


Dilution — 1  :  4 


Dilution—l  :  16 


Dilution— 1  ;  64 


Control,  Not 
Inoculated 


Cutaneous  Rcactinu  Showin.u;  llm  Various  Results  with  Concentrated  anil 
Diluted  TuberciUin.  Taken  48  hours  after  inoculation  by  Dr.  llenning,  at  the 
clinic  of  Eschericii. 


PLATE  XV 


Severe  Cutaneous  Reaction.      Note  the  two  places  inoculated.     The  center 
is  the  control,     (Escherich's  clinic.) 


Scrofulous  Reaction.     Two  outer  places  inoculated.     Tlu; 
center  is  the  control.     (Escherich's  chnic.) 


TUBERCULUSIS.  533 

but  if  there  is  an  absence  of  roseola,  if  the  diazo  reaction  is  absent, 
and  if  the  Widal  reaction  is  absent,  then  miliary  tuberculosis  must  be 
inferred.  The  ophthalmoscopic  examination  must  not  be  looked  upon  as  a 
positive  criterion,  for  miliary  tuberculosis  may  exist  in  spite  of  the  absence 
of  tuberculosis  of  the  choroid.  For  differential  diagnosis  between  tubercu- 
losis and  syphilis,  see  chapter  on  "Syphilis,"  page  723. 

Tiiherciilin. — The  use  of  injections  of  tuberculin  for  diagnostic  as  well 
as  therapeutic  results  dates  back  to  1891,  when  Koch  first  announced  clin- 
ical results.  My  experience  with  tuberculin  at  that  time,  through  the 
courtesy  of  George  F.  Shrady,  at  the  St.  Francis  Hospital,  New  York, 
was  not  very  encouraging.  I  have  also  seen  cases  in  which  tviberculin  was 
used  through  the  courtesy  of  Prof.  Adolpli  Baginsky,  at  the  Berlin  Chil- 
dren's Hospital.  Baginsky  has  never  encouraged  the  'use  of  these 
injections.  In  his  sixth  edition  of  ''Lehrbuch  .  der  Kinderkrank- 
hciten,"  1899,  i)age  350,  he  says:  '"I  do  not  believe  that  the  injection  of 
tuberculin,  especially  in  very  small  children,  is  without  dauger.  I  am 
aware  that  Kossel,  in  Berlin,  uses  the  injections  very  extensively  and  with- 
out ill  results."  He  states  the  minimum  dose  for  an  infant  is  from  1  to 
5  milligrams. 

TUBEECULIX  EeACTIOX   AX   AlD  TO   THE  DIAGNOSIS  OF   LATENT 

Forms  of  Tuberculosis.^ 

Yon  Pirquet  found  tluit  by  iuoeulating  the  skin  with  a  minute  quantity 
of  old  tuberculin  a  local  inllammatory  reaction  is  produced.  There  is  no 
fever  nor  general  systemic  disturbance  after  such  inoculation.  With  the 
older  method  of  Koch  fever  followed  each  injection.  The  technique  is  as 
follows :  Wash  the  arm  with  etber  and  scarify  three  small  areas,  but  not 
enough  to  produce  a  bloody  surface.  Into  two  of  these  scarified  areas  inocu- 
late (similar  to  vaccination)  diluted  tuberculin  of  the  strength  of  one  part 
tuberculin  with  three  parts  normal  saline  solution.  Leave  the  third  scari- 
fied area  without  inoculation  as  a  control.  After  twenty-four,  rarely  later 
than  forty-eigbt  hours,  a  local  iriflammatory  reaction,  about  10  millimeters 
in  width,  surrounding  the  inoculated  area,  denotes  a  positive  reaction.  In 
the  last  stages  of  miliary  tuberculosis  and  tuberculous  meningitis  no  reaction 
follows.    Tlio  opbthalmo  reaction-  is  another  metliod  of  diagnosis. 

Prognosis. — Tbe  success  attained  during  the  last  few  years'*  in  the 
treatment  of  tuberculosis  proves  the  scientific  progress  made.  Several  years 
ago  this  disease  was  erroneously  considered  hopeless. 

'  Coniplotc  litcruture  and  details  |nil>lislicd  in  tlio  Now  York  '^^0(li(■al  Journal, 
October  19.  1007. 

-ralincttc!  advises  usiii<j;  a  Vhh.  I><'r  eeiit.  dilution  of  tuberculin  dropped  into 
the  eye. 

■'"Tuherculosis  and  How  to  ('oMiI)at  it,"  i)vizo  essay  by  S.  A.  Knopf,  is  well 
worth  reading. 


534  THE  IXFECTIOl'S  DISEASES. 

Modern  physicians  recognize  the  importance  of  treating  the  collapsed 
lung  that  has  become  so  through  unsanitary  surroundings,  in  tlie  light  of 
cause  and  effect.  The  prognosis  therefore  will  depend  on  the  age  of  the 
patient,  the  stage  of  the  disease  in  wliich  treatment  is  commenced,  and  the 
will  power  of  the  ])atient.  Tlie  vitality  of  children  and  their  ability  to  pass 
tlirough  long  periods  of  ilhiess  and  fir  ally  recover  sliou'd  be  remembered 
wlien  the  outcome  of  the  case  is  considered.  Severe  forms  of  marasmus, 
with  marked  emaciation,  apparently  hopeless,  finally  recovered.  I  have  also 
seen  severe  forms  of  apex  tuberculosis  in  children  th'it  entirely  recovered 
after  proper  hygienic  and  dietetic  treatment  was  instituted. 

It  is  our  duty  to  instruct  parents  and  those  in  charge  of  children  of  the 
dangers  on  the  one  hand  where  treatment  is  neglected,  and  to  picture  to 
tiiem  on  ihe  other  hand  how  successful  other  cases  have  been  when  the  dis- 
ease was  properly  handled. 

Treatment. — Dietetic  Treatment:  Next  to  sunshine,  fresh  air,  and 
pulmonary  gymnastics  comes  nutrition.  A  child  that  is  properly  strength- 
ened with  milk,  buttermilk,  cocoa,  eggs,  cereals,  cheese,  green  vegetables, 
fruits,  meats,  and  meat  broths  will  certainly  be  better  able  to  recover  than 
one  that  is  underfed. 

One  roint  Concerning  Feeding. — ]\Iilk  if  given  should  not  be  repeated 
oftencr  than  once  in  four  hours.  The  yolk  of  a  fresh  egg  may  be  added 
just  before  feeding.  When  soup  is  given  the  yolk  of  a  fresh  egg  may  be 
added  to  it.  T  frequently  give  the  yolks  of  eight  or  ten  eggs  in  twenty-four 
hours  if  the  gastric  condition  warrants  the  same. 

Strict  attention  must  be  paid  to  the  bowels  so  that  we  do  not  overfeed 
and  i^roduce  a  dyspepsia  by  overfeeding.  If  milk  is  not  well  borne  it  may 
be  peptonized. 

General  I'reatnient. — Jn  the  treatment  of  tuberculosis  the  most  im- 
portant point  to  remember  is  that  fresh  air  is  the  best  lung  disinfectant 
that  we  possess.  No  remedy  will  kill  tubercle  bacilli  as  quickly  as  sunshine 
and  fresh  air.  This  should  be  impressed  on  every  family  wherein  a  case 
of  tuberculosis  is  found.  The  progress  made  in  recent  years  by  climatic 
treatment  has  demonstrated  the  fact  that  cavities  in  the  lung  will  frequently 
heal  under  proper  treatment.  The  open-air  treatment  has  gained  such  a 
strong  foothold  that  we  do  not  encounter  the  same  difficulties  that  we  did 
years  ago  wlien  recommending  open  windows  night  and  day.  The  great 
bugbear  of  night  air  should  l)e  removed,  because  fresh  air  at  night  is  equally 
as  important  as  it  is  by  day. 

Hygienic  Tna'.ment. — 1'he  value  of  sunshine,  fresh  air,  and  outdoor 
life,  best  known  as  the  hygienic  treatment  of  tuberculosis,  must  not  be 
forgotten.  To  cure  any  case  of  tuberculosis  by  an  indoor  life  is  out  of  the 
question.  When  exercise  can  be  taken  ii  slionld  l)e  insisted  upon,  as  thereby 
we  stimulate  metabolism  and  increase  ilie  power  of  assimilatin<i  food. 


TUBERCULOSIS.  535 

Pulmonary  Gymnusiics. — Deep  inspiration  and  expiration  will  oxy- 
genate the  lungs  when  regularly  performed. 

Deep  breaths  taJcen  in  the  mountains  on  lohich  there  are  pine-needle 
trees  will  do  more  toward  expanding  and  impregnating  diseased  or  collapsed 
portions  of  the  lung  than  will  the  inhalation  of  a  hundred  times  that  quan- 
tity of  pine-needle  oil  in  the  close  stuffy  room  when  diffused  from  an  atom- 
izer. The  hygienic  treatment  must  not  be  confined  to  walking  and  breath- 
ing the  pure  air,  but  must  be  aided  by  tepid  bathing  and  by  stimulating  the 
circulation  of  the  blood  by  friction  with  a  coarse  Turkish  towel.  Sea  salt 
can  be  added  to  the  bath.  When  the  feet  or ii and s  are  cold  they  should  be 
briskly  rubbed  until  the  blood  circulates  freely. 

Medicinal  Treatment. — Codliver-oil  internally  should  be  tried.  If  it 
is  not  well  borne  it  can  be  used  by  external  friction  over  the  whole  body, 
daily  for  ten  or  fifteen  minutes.  This  is  the  so-called  codliver-oil  bath. 
If  codliver-oil  is  not  tolerated,  butter  should  be  given  in  large  quantities. 
Codeine  in  ^/k,  to  ^/^-grain  doses  can  be  given,  or  heroin  in  V50  to  ^/ag- 
grain  doses,  three  times  a  day,  may  be  given  to  relieve  cough.  For  the 
relief  of  the  night  sweats  sulphate  of  atropine,  ^f^-,,^  to  ^/^qq  of  a  grain, 
three  times  a  day.  should  be  given.  Toxic  symptoms  should  always  be 
looked  for  in  the  pujiils  when  administering  these  drugs.  A  laxative  dose 
of  citrate  of  magnesia  or  calcined  magnesia,  5  to  10  grains,  several  times  a 
day,  is  useful.  Creosote  carbonate,  5  to  20  drops,  three  times  a  day,  given 
in  the  form  of  an  emulsion,  has  served  me  very  well. 

IJ   Creosote  carbonate    1   drachm 

Mucilage  acacia   1  ounce 

Emulsion  amygd.  dulc q.  s.  ad  2  ounces 

Sig. :      One  drachm  three  or  four  times  a  day. 

If  blood  is  expectorated,  then  5  to  15  drops  of  fluid  extract  of  ergot 
can  be  given  -every  few  hours.  In  other  cases  0  to  10  grains  of  powdered 
alum,  repeated  every  few  hours,  may  do  good.  I  have  also  seen  good  results 
from  5  and  10-grain  doses  of  gallic  acid.  Fluid  extract  of  hydrastis  cana- 
densis, 3  to  10  drops,  several  times  a  day,  or  hydrastinine  hydrochlorate, 
Vioo  grain,  three  times  a  day,  may  be  tried. 

Tincture  of  iron  in  5  to  10-drop  doses,  is  a  good  hemostatic;  besides 
it  is  a  valuable  tonic.  Stimulation  is  sometimes  required.  Old  rye  whisky, 
wine  or  champagne  is  indicated.  It  not  only  stimulates  but  promotes  the 
appetite  in  debilitated  cases. 

clihoxic   1*1  l.moxahy  tuberculosis.     (tuberculous 
Broxcho   Pxeumoxia.) 
This  condition   is   rarely   found    in   infants  and  very  young  children. 
When  chronic  pulmonary  tuberculosis  is  noted  it  is  usually  seen  in  children 
after  the  sixth  or  eiditli  vear. 


536 


THE  INFECTTOrS  DISEASES. 


Pathology. — Osier  states  that  small  cavities  are  by  no  means  rare  in 
chronic  pulmonary  tuberculosis  of  children,  but  very  large  excavations  are 
rare;  thus  in  2G5  cases  noted  by  Barthez  and  Sanne  there  were  77  cases 
with  excavation,  chiefly  in  the  n])])er  ]ol)es.    In  the  analysis  by  Leronx  of 


12     13    14     15     16     17     13     19   20    21   22   23  24  25 


Fig.  161. — Fever  curve  during  the  early  period  of  Chronic  Pulmonary 
Tuberculosis.  The  daily  exoiirsions  are  slight,  and  generally  range  between 
102°  and  104°  F.      (Original.) 

the  cases  of  the  late  Parrot,  in  219  children  under  2  years  of  age, 
there  were  57  instances  in  which  cavities  existed.  In  five  of  these  the 
children  were  under  three  months.  In  long-standing  cases  hard,  firm, 
fibrons  tubercles  are  found,  and  sometimes  cutaneous  nodules.     The  pri- 


Fig.  162. — Temperature  curve  during  the  fifth  month,  when  the  disease 
is  more  extended  and  .softening  has  taken  place  with  the  formation  of  cavities. 
The  temperature  is  more  hectic  in  character.  The  morning  temperature 
may  be  nonnal  or  subnormal,  while  the  evening  temperature  laiiges  between 
10.3°  and  10.")°  F.      (Original.) 


mary  lesion  in  a  great  majority  of  instances  is  a  tuberculous  broncho- 
pneumonia, taking  its  origin  in  the  smaller  bronchioles,  leading  to  peri- 
bronchial nodules  and  subsequent  peribronchial  alveolitis.     The  lesions  are 


TUBERCULOSIS. 


637 


similar  to  tho«e  met  with  in  the  tuberculosis  of  adults — miliary  tubercles, 
peribronchial  nodules,  caseous  blocks,  areas  of  softening  and  of  fibroid 
induration,  and  cavities  of  various  sizes.  We  do  not  see  so  frequently  the 
invasion  of  the  lung  from  the  apex  downward.     The  chief  seat  of  disease 


Fig.  103. — Chronic  Nodular  Tuberculous  Bronoho-pneuinoniii.  (a,  h,  c,  d) 
tuberculous  foci  of  variable  size  and  sliape,  corresponding  to  the  infiltrated 
alveolar  system;  (e)  transverse  section  through  an  infiltrated  occluded  bron- 
chiole; ffj  small  arterial  branch;  fg)  group  of  nodules  undergoing  coales- 
cence;   (JtJ  small  unaltered  bronchus;    (kj  artery.    XG.     (Ziegler.) 


may  be  in  the  central  portion  of  the  lung,  or  even  at  the  base.  In  tuber- 
culosis of  the  lymph  glands,  the  groups  along  the  trachea  and  about  the 
bronchi  may  be  greatly  enlarged  and  caseous,  forming  on  sectioii  a  very 
striking  feature  in  the  chronic  pulmonary  tuberculosis  of  children. 

Symptoms. — Chronic  pulmonary  tuberculosis  in  the  child  presents  the 
same  symptoms  as  in  the  adult.  Usually  a  broncho-pneumonia  will  first  be 
encountered,  or  the  symptoms  present  will  resemble  those  of  a  broncho- 


538  THE  INFECTIOUS  DISEASES. 

l)neumonia.  When  fever  persists  and  there  are  evidences  of  a  general 
breakdown,  such  as  mahiise,  loss  of  appetite,  and  emaciation  with  or  with- 
out cough,  then  this  condition  must  be  suspected.  When  these  children 
expectorate,  the  same  resembles  that  seen  in  adults.  Tubercle  bacilli  have 
frequently  been  found  in  the  expectoration  of  cases  under  my  care.  Blood 
spitting  in  which  the  nmcus  is  blood-stained  has  been  seen  by  me.  The 
blood  is  bright  red  in  color.  Epistaxis  is  sometimes  seen  during  the  course 
of  the  disease.  The  temperature  ranges  between  100°  and  102°  F.  in  the 
beginning  of  the  disease;  later  on  it  assumes  the  real  hectic  character; 
thus,  the  temperature  may  be  99°  to  100°  F.  in  the  morning,  and  103°  to 
105°  F.  in  the  evening. 

Pleuritic  pains  are  complained  of  in  various  parts  of  the  chest.  There 
is  marked  dyspnoea  and  frequently  cyanosis.  Osier  states  that  some  cases 
do  not  have  any  pain  throughout  the  course  of  the  disease.  A  general 
emaciation  associated  with  muscular  weakness  and  anaemia  is  usually  seen 
later  in  the  disease.  Tubercular  ulceration  of  the  intestine  will  frequently 
cause  diarrhoea.  In  a  child  seen  by  me  with  chronic  tuberculosis  of  the 
lungs,  a  general  anasarca  was  present. 

Katie  B.,  8  years  old,  has  been  a  very  delicate  child.  She  was  breast  and 
bottle-fed,  and  lived  in  a  tenement  house. 

Famllii  Historj/.— The  father  was  a  drunkard  and  did  not  support  his  family; 
the  mother  is  a  frail  ansemic  woman,  although  no  evidence  of  pulmonary  disease 
could  be  found.  The  child  was  late  in  walking,  late  in  teething,  and  late  in  talking. 
Distinct  evidence  of  rickets  of  the  bones  was  everywhere  noted.  When  4  j'ears 
old  the  child  had  measles,  complicated  with  broncho-pneumonia,  after  which  a 
cough  remained.  Three  months  after  the  measles  the  child  still  coughed  ami 
showed  evidences  of  malnutrition.  The  cough  persisted  in  spite  of  codliver-oil, 
malt  extract,  and  iron,  which  was  liberally  given.  As  the  family  were  poor 
they  could  not  take  the  child  to  the  country  for  a  complete  change  of  air.  I  did 
not  see  the  case  again  for  two  years,  when  I  saw  it  through  the  courtesy  of  Dr. 
John  H.  Wurthman.  At  this  time  she  had  a  cavity  at  the  apex  of  the  right  lung,  was 
terribly  emaciated,  and  complained  of  pain  on  breathing  and  suffered  with  marked 
dyspnoea.  Pleuritic  friction  sounds  were  heard  over  small  areas  of  the  chest  on 
both  sides.  The  child  had  haemoptysis  besides  a  purulent  expectoration.  Tubercle 
bacilli  were  found  in  the  sputum.  She  died  after  a  violent  haemorrhage,  from  ex- 
haustion and  heart  failure. 

The  treatment  is  the  same  as  described  in  the  article  on  "Acute 
Tuberculosis.'* 


CHAPTEE  VI. 

ACUTE  DIPHTHERIA. 

Diphtheria  is  an  acute  infectious  disease  caused  by  the  invasion  of  a 
specific  micro-organism  known  as  the  Klebs-Loeffler  bacillus. 

It  is  a  disease  characterized  by  the  presence^,  locally,  of  false  mem- 
branes, known  as  pseudo-membranes. 

Etiology. — This  disease  is  most  frequently  met  with  in  children,  al- 
though adults  are  not  exempt  from  it.  It  is  met  with  in  the  newly  born 
(Jacobi).  It  is  most  frequently  seen  about  the  second  year.  Children  are 
especially  disposed  to  this  disease  between  the  ages  of  1  and  5  years.  Bagin- 
sky  re^jorts  a  series  of  2T11  cases  in  which: — 

84  occurred  during  the  first  year. 
889  between  the  first  and  fourth  year. 
1411  between  the  fourth  and  tenth  year. 
318  between  the  tenth  and  fourteenth  year. 

There  is  no  difference  in  the  sex  regarding  the  predisposition  to 
diphtheria : — 

1311  in  the  above  series  were  boys. 
1400  were  girls. 

Infection  is  spread  primarily  by  contact.  It  can  be  transmitted 
through  dishes,  play  toys,  and  furniture  to  wliich  the  Klebs-Loeffler  bacilli 
adhere.  Infections  have  been  traced  to  water  and  milk  which  contained 
the  diphtheria  bacillus.  We  know  that  the  Klebs-Loeffler  bacilli  adhere 
to  the  walls  and  ceilings  of  rooms.  The  etiology  of  diphtheria  remained 
obscure  until  Loeffler  discovered  the  bacillus  in  1884. 

Sewer  gas  is  not  looked  upon  as  a  cause  of  diphtheria  per  se.  When  the 
system  is  poisoned  by  sewer  gas  it  will  offer  less  resistance  to  the  infection 
of  the  Klebs-Loeffler  bacillus  than  otherwise. 

Unhealthy  Throats. — The  presence  of  diseased  tonsils,  or  adenoid 
vegetations  in  the  pliarynx,  are  usually  foci  for  the  development  and 
propagation  of  the  Klebs-Loeffler  bacillus.  The  writer  has  frequently  ques- 
tioned the  patients  at  the  Willard  Parker  IIos])ital  regarding  former  throat 
diseases.  It  was  rare  to  find  a  throat  infected  with  diphtheria  that  did  not 
have  ])r(>vious  tonsillar  or  other  throat  disease. 

I'lius  it  would  appear  wise  to  ])ut  the  throat  in  as  healthy  a  state  as 

(539) 


540 


THE  INFECTIOUS  DISEASES. 


})ossiblo  in  order  to  prevent  the  opportunity  for  receiving  an  infection  of 
diphtlieria. 

False  di})litlu'ria.  in  which  tliere  is  a  non-virulent  germ  present,  fre- 
quently reseniblof;  diphtheria. 

Hunt's  diilerential  stain  and  also  the  Neisser  stain  will  differentiate 
the  non-virulent  from  the  virulent  form  of  germ. 

Table  No.  72. — Deaths  from  Diphtlieria  and  Croup,  in  Children  under  15 
Years — (Old)  City  of  New  York. 


0 
Year. 

1 
Year. 

2 
Years. 

3 
Years. 

4 

Years. 

Under 
5  Yrs. 

5-10 
Years. 

10-15 
Years. 

1890 

Males 
Females 

913 
843 

9!) 
71 

233 

188 

193 

180 

145 
163 

92 
90 

762 

691 

143 
139 

8 
13 

1891 

Males 
Females 

1000 
984 

111 

85 

232 

232 

210 
203 

173 
167 

187 
181 

111 
95 

123 
108 

837 

752 

155 
172 

8 
10 

1893 

Males 
Females 

1101 
968 

93 
67 

269 

223 

270 

305 

941 

783 

148 
173 

12 

12 

1893 

^lales 
Females 

1241 

1278 

98 
110 

300 
273 

378 
276 

218 
199 

131 
137 

167 

167 

1015 
995 

211 
361 

15 
22 

1894 

Males 
Fc-males 

1456 
1386 

125 
109 

130 

84 

351 
301 

311 
306 

253 

2^8 

1207 

nil 

233 

255 

16 
20 

1895 

Males 
Females 

1000 
946 

247 
232 

200 

217 

175 

138 

103 
94 

854 
765 

138 
169 

8 
12 

1896 

Males 
Females 

872 

859 

756 

811 

96 
65 

241 
197 

196 
213 

193 

188 

112 

141 

100 
101 

742 
693 

119 
151 

11 
16 

1897 

Males 
Females 

82 
74 

169 
156 

106 
122 

75 
76 

628 
641 

391 
330 

118 
164 

10 
6 

1898 

Males 
Females 

456 
442 

53 
35 

149 
101 

91 
94 

57 
61 

42 
48 

45 
59 

59 
92 

6 
11 

1«99 

Males 
Females 

518        62 
544        52 

133 

149 

107 
112 

88 
86 

431 

458 

76 

78 

7 
8 

1900 

1 
Males                 647        72 
Females            589        64 

147 

108 

172 
123 

116 

115 

119 
89 

62 

75 

516 
451 

511 
483 

114 
126 

17 
12 

1901 

Males                 600         6t 
Females             r>m        77 

122 
129 

102 
90 

51 
64 

89 
99 

6 
16 

DIPHTHERIA. 


541 


Table.  No.   73. — Per  Cent,  of  3fort  tlity  from  DipJi'heria  in  different  Cities  of  ihe 

United  States. 


Cities. 

Treatmeut. 

isyo. 

1896. 

1897. 

1898. 

1899. 

1900. 

1901. 

1902. 

Baltimore,  Md. 
Ualtiniore   Md. 

No  antitoxin  . 
With  antitoxin 

19.83 

9.8 

17.52 
9.8 

15.01 
9.8 

14.62 

8.3 

13.37 

6.87 

Lowell,  Mass. 
Lowell,  Mass. 

No  antitoxin  . 
With  antitoxin 

48. 0 
28.0 

56.0 
10.0 

27.0 
9.0 

35  0 
9.0 

39.0 
12.0 

30.0 
4  0 

30.0 
11.0 

26.0 
8.0 

Newark,  N.  J. 
Newark,  N.  J. 

No  antitoxin  . 
With  antitoxin 

230 
13.0 

31.0 
11.0 

19.0 
11.0 

17.5 
10.5 

14.5 

8.77 

14.6 
8.1 

22.7 
6.6 

19.0 
70 

Eochester,  N.Y. 
Eochester,N.V. 

No  antitoxin  . 
With  antitoxin 

23.7 
12.24 

2L7 
9.6 

23.9 
9.0 

17.5 
9.7 

18.7 
6.5 

8.9 
8.4 

10.96 
6.97 

Bacteriology. — In  the  year  1883  bacilli,  which  were  very  peculiar 
and  striking  in  appearance,  were  shown  by  Klebs  to  be  of  con- 
stant occurrence  in  the  pseudo-membranes  from  the  throats  of  those 
dying  of  true  epidemic  diphtheria.  One  year  later  Loeffler  pub- 
lished the  results  of  a  very  thorough  and  extensive  series  of  investiga- 
tions on  this  subject.  He  found  the  bacillus  described  by  Klebs  in  most 
but  not  all  cases  of  throat  inflammations  which  had  been  diagnosticated  as 
diphtheria.  He  separated  these  bacilli  from  the  other  bacteria  present 
and  obtained  them  in  pure  culture.  When  he  inoculated  these  bacilli  upon 
the  abraded  mucous  membrane  of  susceptible  animals,  pseudo-membranes 
were  produced,  and  frequently  death  followed.  If  a  certain  amount  of  a 
bouillon  culture  was  injected  subcutaneously  into  guinea  pigs,  death  was 
caused  Avith  characteristic  lesions.  Loeffler's  failure  to  find  the  bacilli  in 
every  case  examined  is  now  explained  by  the  fact  that  certain  varieties  of 
pseudo-membranous  inflammation  not  due  to  the  diphtheria  bacillus,  such 
as  occur  especially  in  scarlet  fever,  were  then  wrongly  considered  to  be  true 
diphtheria. 

"In  1887  further  studies  by  Loeffler  added  to  tlie  proof  of  the  depend- 
ence on  the  diphtheria  bacilli.  In  1888  D'Espine  found  the  bacilli  in  14 
cases  of  cliaractcristic  diphtheria,  and  proves  them  to  be  absent  in  24  cases 
of  mild  sore  throats,  which,  clinically,  were  believed  not  to  be  cases  of  diph- 
theria. In  the  same  year  the  first  portion  of  the  results  of  the  very  impor- 
tant investigations  of  Eoux  and  Yersin  was  published,  and  tlie  dependence 
of  diphtheria  bacilli  may  be  considered  to  have  been  established.  Eoux 
and  Yersin  found  the  diphtheria  bacilli  were  present  in  all  characteristic 
cases  of  diphtheria,  and  that  tliese  bacilli  ])ossessed  the  cultural  and  patho- 
genic qualities  of  those  described  by  Loeffler.  'I'liey  found,  too,  when  the 
bacilli  were  inoculated  upon  flic  licalfhy  mucous  mcrfubrane  of  the  trachea 


542  I'llK   INFECTIOUS  DISEASES. 

of  the  rabbit,  no  result  followed ;  but,  if  the  inoculation  was  made  on  the 
abraded  membrane,  phenomena  occurred,  which  strikingly  resembled  those 
present  in  membranous  laryngitis  in  man,  i.e.^  congestion  of  the  mucous 
membrane,  followed  by  the  formation  of  the  pseudo-membrane,  oedematous 
swelling  of  the  tissues  and  of  the  glands  of  the  neck,  dyspnoea,  stridulous 
breathing  and  asphyxia.  Injections  of  cultures  beneath  the  skin  of  rabbits 
and  guinea-pigs  in  sufficient  quantity  caused  their  death  in  from  thirty-six 
hours  to  five  days,  the  period  varying  in  ratio  to  the  susceptibility  of  the 
animal,  and  the  number  and  violence  of  the  bacteria  introduced.  The 
same  result  followed  the  injections  of  filtered  cultures,  showing  the  products 
formed  by  the  growth  of  the  bacilli  were,  by  themselves,  capable  of  causing 
the  general  lesions. 

"Roux  and  Yersin  were  also  able  to  produce  in  animals  characteristic 
diphtheria  paralysis.  They  produced  this  in  many  cases  where  the  inocu- 
lated animal  did  not  succumb  to  a  too  rapid  intoxication.  Paralysis  com- 
menced in  a  pigeon  three  weeks  after  the  inoculation  of  the  pharynx  after 
all  membrane  had  disappeared,  and  the  animal  seemed  to  have  completely 
recovered. 

"In  rabbits  the  paralysis  usually  commenced  in  the  posterior  extremi- 
ties and  then  gradually  extended  to  the  whole  body,  causing  death  by 
paralysis  of  the  heart  or  respiration.  In  rare  instances,  the  muscles  of  the 
neck  or  larynx  sfere  first  paralyzed,  and  thus  characteristic  symptoms  were 
caused. 

"The  authors  conclude :  'The  occurrence  of  these  paralyses,  follow- 
ing the  introduction  of  the  bacilli  of  Klebs  and  Loeffler,  completes  the  re- 
semblance of  the  experimental  disease  to  the  natural  malady,  and  estab- 
lishes with  certainty  the  specific  rule  of  this  bacillus.' 

"Finally,  the  microscopic  changes  in  the  internal  organs  of  animals 
dying  of  experimental  diphtheria  produced  by  the  bacilli  have  been  shown 
by  "Welch  and  Flexner,  and  by  Babes  and  others,  to  be  essentially  the  same 
as  those  produced  by  diphtheria  in  man,  and  thus  a  still  further  proof  is 
afforded  of  the  specific  rule  of  this  bacillus." 

The  reason  for  the  various  observations  detailed  above  have  since  been 
confirmed  In'  a  great  number  of  combined  clinical  and  bacteriological  in- 
vestigations, so  that  all  who  have  studied  the  bacteriology  of  diphtheria 
would  now  agree  with  the  following  statement  made  by  Welch  in  an  ad- 
dress on  diphtheria:  "All  the  conditions  have  been  fulfilled  for  diphtheria 
which  are  necessary  to  th-e  most  rigid  proof  of  the  dependence  of  an  infec- 
tious disease  upon  a  given  micro-organism,  viz. :  the  constant  presence  of 
this  organism  in  the  lesions  of  the  disease,  the  isolation  of  the  organ- 
ism in  pure  culture,  the  reproduction  of  the  disease  by  inoculation  of  pure 
cultures,  and  similar  distribution  of  the  organism  in  the  experimental  and 
the  natural  disease.     In  view  of  these  facts  we  must  agree  with  Prudden 


DIPHTHERIA.  543 

that  we  are  now  justified  in  saying  that  the  name  diphtheria,  or  at  least 
primary  diphtheria,  should  be  applied,  and  exclusively  applied,  to  that 
acute  infectious  disease  usually  associated  with  pseudo-membranous  affec- 
tions of  the  mucous  membrane  which  is  primarily  caused  by  the  bacillus 
diphtherige  of  Loeffler/' 

The  germs  cannot  be  found  in  the  blood,  but  usually  in  the 
membranes.  Xow  and  then  the  specific  germ  may  not  be  easily  found 
in  the  pseudo-membranes.  When  such  is  the  case,  several  cultures  may  be 
necessary  to  demonstrate  the  presence  of  the  Klebs-Loeffler  bacillus.  This 
bacillus  is  most  easily  found  in  the  older  pseudo-membranes. 

Frequently  we  find  the  streptococcus  or  the  staphylococcus  accom- 
panying the  Klebs-Loeffler  bacillus.  We  are  not  justified  in  pronouncing 
the  visible  pseudo-membrane  diphtheria  unless  we  find  the  Klebs-Loeffler 
bacillus  present. 

When  there  is  a  pseudo-membrane  present  and  the  Klebs-Loeffler  ba- 
cillus cannot  be  found,  then  a  provisional  diagnosis  of  diphtheria  can  be 
made. 

Technical  errors  will  sometimes  occur  in  the  taking  of  cultures  or  in 
inoculating  culture  media.  Thus  the  germ  may  not  be  found.  The  rule 
always  followed  by  the  writer  is  to  isolate  every  patient  having  visible  mem- 
branes until  the  same  have  disappeared. 

The  bacillus  can  frequently  be  transmitted  through  animals.  Cows, 
cats,  dogs,  and  pigeons  having  diphtheria  can  easily  infect  those  coming 
in  contact  with  them.  Cows'  milk  can  transmit  the  disease  if  the  Klebs- 
Loeffler  bacillus  exist  therein. 

Characteristics  of  the  Loeffler  Bacillus. — The  diameter  of  the  bacilli 
varies  from  0.3  to  0.8  micro-millimeters,  and  the  length  from  1.5  to  G.5 
micro-millimeters.  They  occur  singly  and  in  pairs,  and  very  infrequently 
in  chains  of  three  or  four.  The  rods  are  straight  or  slightly  curved,  and 
usually  are  not  uniformly  cylindrical  throughout  their  entire  length,  but 
are  swollen  at  the  ends,  or  pointed  at  the  ends  and  swollen  in  the  middle 
portion.  Even  from  the  same  culture  different  bacilli  vary  greatly  in  their 
shape  and  size.  The  two  bacilli  of  a  pair  may  lie  with  their  long  diameter 
in  the  same  axis,  or  at  an  obtuse  or  an  acute  angle.  The  bacilli  possess 
no  spores,  but  have  in  them  highly  refractile  bodies.  They  stain  readily 
with  the  ordinary  aniline  dyes  and  retain  their  color  after  staining  by 
Gram's  method.  With  an  alkaline  solution  of  methylene  blue,  the  bacilli, 
from  blood  serum  especially,  and  from  other  media  less  constantly,  stain  in 
an  irregular  and  extremely  characteristic  way,  namely,  club-shaped. 

The  bacilli  do  not  stain  uniformly.  Certain  oval  bodies  situated  in 
the  ends,  or  in  the  central  portions,  stain  much  more  intensely  than  the  rest 
of  the  bacillus.  Sometimes  these  highly  stained  bodies  are  thicker  than  the 
rest  of  the  bacillus,  again  they  are  thinner  and  surrounded  by  a  more  slightly 


544  THE   INFECTIOUS  DISEASES. 

stained  portion.  The  bacilli  seem  to  stain  in  this  peculiar  wa}'  at  a  certain 
period  in  their  growth,  so  that  only  a  portion  of  the  organisms  taken  from 
a  culture  at  an}^  one  time  will  show  the  characteristic  staining.  In  old 
cultures,  it  is  often  dillieult  to  stain  the  bacilli,  and  the  staining,  when  it 
does  occur,  is  frequently  not  at  all  characteristic. 

Growth  on  Blood  Senun. — If  wc  examine  the  growth  of  the  diph- 
theria bacillus  in  pure  culture  on  blood  serum,  we  will  find  at  the  end  of 
ten  to  twelve  hours  little  colonies  of  bacilli,  which  appear  as  pearl-gray  or 
whitish-gray  slightly  raised  points.  The  colonies  when  separated  from  each 
other  may  increase  in  forty-eight  hours,  so  that  the  diameter  may  be  V4 
inch.  The  borders  are  usually  somewhat  uneven.  These  colonies  lying 
together  fuse  into  one  mass,  especially  if  the  serum  is  rather  moist.    During 


Fig.  1G4. — Diphtlipria  or  Klebs-Loeffler  bacilli;    smear  preparation  from  ton- 
sillar deposit.     Loefiier's  stain.     X800.      (Lenhartz-Biooks.) 


the  first  twelve  hours,  the  colonies  of  the  diphtheria  bacilli  are  about  equal 
in  size  with  those  of  the  streptococci;  but  after  this  time  the  diphtheria 
colonies  become  larger  than  those  of  the  streptococci,  nearly  equaling  those 
of  the  staphylococci.  The  diphtheria  bacilli  in  their  growth  never  liquefy 
the  blood  serum. 

The  Relation  Between  the  Length  of  tlte  Bdcillus  and  its  Virulence. — 
Some  investigators  believed  that  the  degree  of  virulence  possessed  by  the 
diphtheria  bacilli  could,  to  a  certain  extent,  be  judged  by  their  length. 
Tlie  longest  bacilli  were  supposed  to  be  the  most  virulent;  those  of  medium 
length  less  so,  and  the  shortest,  little  if  at  all  virulent.  By  observing 
this  characteristic  it  was  thought  cultures  might  become  helpful  in 
prognosis. 


DIPHTHERIA. 


545 


"The  short  Klebs-Loeffler  baciUus  apparently  produces  a  toxin  of 
greater  virulency  than  the  hirger  forms,  although  the  local  manifestations 
mav  not  he  so  extensive.^ 


\  ^u 


V 


r" 


• '.  <•*   *  - 


:»> 


-^^ 


,?,*,■*  ft«i 


d. 


e.  ^ 

Fig.  Ifio. — Tnio  and  False  Diphthoria.  fa)  Diphtheria  l)aciili  xlOO 
diameter;  (b)  chararteristic  diphtheria  bacilli  xlOOO.  (r)  colonies  of  diph- 
theria bacilli  xl24  diameters;  (d)  even  stained  short  diphtheria  bacilli  xlOOO; 
(e)  pseudo-diphtheria  bacilli  XlOOf);  (f)  streptococci  smeared  directly  upon 
cover  glass  from  throat  exudate  XlOOO.      (After  Park.) 

"The  long  Kk4js-Loelller  Ijacillus   and   the   sirei)tococci,   when   found 
alone,  give  rise  to  a  mild  type  of  the  disease. 

"The  streptococcus  is  found  associated  Avith  7\lchs-Loeffler  bacillus  in 

^X.  J.  Class   (X.  Y.  ISIedical  Journal,  :May   14,  1897). 


540 


THE  INFECTIOUS  DISEASES. 


most  severe  cases.  Tts  special  significance  is  not  so  clear,  but  it  is  possible 
that  by  causing  a  more  intense  inflannnatory  reaction  it  opens  avenues  by 
which  the  toxins  of  the  Klehs-Looillcr  bacillus,  plus  its  own  toxin,  may  find 
more  ready  entrance  into  the  circulation. 

"Tlie  apparent  beneficial  action  of  the  antitoxin  of  the  Klebs-Loeffler 
bacillus  in  cases  where  this  bacillus  is  not  present  uuiy  be  due  to  the  fact  that 
though  the  local  action  of  the  different  microbes  varies  to  a  considerable  ex- 
tent, the  action  of  their  toxins,  as  is  shown  by  the  similarity  of  the  constitu- 
tional symptoms  produced  by  them,  presents  many  kindred  features.  The 
thought  therefore  arises  that  the  antitoxin  of  one  infection  may  have  an  in- 
liibitory  effect  on  the  toxin  of  another  as  is  shown  by  the  fact  that  whooping- 
cough  and  some  other  infectious  diseases  have  been  shown  to  occur  less  fre- 
quently in  vaccinated  persons,  and  some  cases  have  a])parently  been  cured 
by  vaccination. 

"By  the  term  Klel)s-Loeffier  bacillus  is  meant  the  medium-sized  bacillus 
as  described  by  ]\Iartin." 

A^ery  careful  notes  have  been  made  on  this  point  in  the  examination  of 
the  bacteria  from  the  original  serum  tubes  in  1613  cases. 

The  results  of  the  examinations  are  shown  in  the  following  table: — 

Taei.e  No.  74. 


No  of  Cases. 

Mortality. 

r>;it'ilU  of  averajie  size  found  in 

liiicilli  longer  tbau  average  in        .    .                

1398 
82 
67 

C6 

26  per  cent. 

27  per  cent. 
35  per  cent. 

12  per  cent. 

Bacilli  shorter  than  average  in  .    . 

liiicilli  short,  not  characteristic  in  shape  and  evenly  stained, 
of  which  many  were  pseudo-diphtheria  bacilli  ... 

Xuiii])er  of  cases  examined        

1613 

"The  results  obtained  from  this  examination  of  1613  cultures,  therefore, 
indicate  that  in  New  York  the  great  majority  of  cases  of  dipntheria  yield  in 
cultures,  bacilli  of  medium  size,  which  are  characteristic  in  shape  and  man- 
ner of  staining.  In  a  moderate  number  of  cases  the  bacilli  foimd  are  much 
longer,  and  in  about  an  equal  number  they  are  much  shorter.  Both  the 
clinical  histories  and  the  animal  experiments  show  that  whenever  in  their 
shape  and  in  the  way  in  which  they  take  the  staining  fluid  the  bacilli  are 
characteristic,  no  information  as  to  their  virulence,  either  in  men  or  ani- 
mals, can  be  gathered  from  their  length.  Those  bacilli,  on  the  other  hand, 
which  are  short  and  stain  uniformly  with  methylene  blue,  usually  jirove  to 
be  of  the  pseudo-diphtheria  type,  and  have  no  vinilence  in  animals." 

Pathology. — The  pathological  lesions  are  caused  by  the  specific  action 
of  the  Klebs-Loeffler  bacillus  and   the  associated   pathogenic  bacteria.     In 


DIPHTHERIA. 


547 


'•        T^^       « 


^-f'^ 


^?^?^^»« 


I  >:. 


'»'*.*  *^ 


LV   •■^°'     •>»',    '/>  V      *»o„   '*fo"o       'o/J'.        '"o'o"     ""'      ."    ''        ».•  «      M 


Fig.  100. — Spction  from  an  inflamed  uvula  covoroil  with  a  stratified 
fibrinous  membrane,  from  a  case  of  diphtheritic  croup  of  the  pharyngeal 
organs  (Miiller's  fluid,  haematoxylin,  eosin).  (a)  Surface  layer  of  coagulum, 
consisting  of  epithelial  plates  and  fibrin  and  containing  numerous  colonies 
of  cocci;  (b)  second  layer  of  coagulum,  consisting  of  fine-meshod  fibrin  net- 
work enclosing  leucocytes;  (cj  third  layer  of  coagulum,  lying  u;on  the  con- 
nective tissue,  and  consisting  of  a  wide  meshed  reticulum  of  iibrin  enclosing 
leucocytes;  fdj  connective  tissue  infiltrated  with  cells;  (r)  infiltrated  bound- 
ary layer  of  the  connective  tissue  of  the  nuicous  membrane;  (f)  heaps  of  red 
blood-cells;  fg)  widely  dilated  blood-vessels;  (h)  dilated  lymph-ves  els  filled 
with  fluid,  fibrin,  and  leucocytes;  (i)  duct  of  a  mucoiLs  gland  distended  wi'h 
secretion;  fkj  transverse  section  of  a  gland;  fl)  fil)rin  reticulum  in  the  super- 
ficial layer  of  connective  tissue.    X45.     (Ziegler.) 


548 


THE   INFECTIOUS  DISEASES. 


addition  thereto  tlie  toxins  geiicralcd  l)y  tlic  various  niiero-organisnis  pro- 
duce local  destructive  changes. 

As  a  rule,  the  local  pathological  lesion  is  a  whitish,  yellowisli-white, 
or  grayish-white  membrane,  which  is  firmly  adherent.  In  some  instances 
a  distinct  greenish  or  black  color  (gangrenous  type)  is  evident. 

In  a  study  of  tlie  pathology  of  220  fatal  cases  of  diphtheria  by  Mal- 
lory.  Councilman,  and  Pearce  they  found  two  varieties  of  membrane;  first, 
a  dense,  firm,  elastic  membrane  composed  of  a  reticular  structure  with 
considerable  imiformity  in  the  size  of  the  beams  composing  it.  This  mem- 
brane can  be  stripped  off  in  large  flakes.  Second,  a  more  friable  variety 
composed  of  fibrin  forming  a  reticulum  with  more  irregular  spaces  and 
fibers.  The  fibrin  spaces  contain  leucocytes,  amongst  which  are  found  some 
broken  down  cells  (detritus).  The  epithelium  below  the  membrane  con- 
tains polynuclear  leucocytes  and  lymphocytes. 

The  interval  lesions  of  diphtheria  are  those  resulting  from  degenerative 
clianges  affecting  organic  structures.  As  a  rule,  hemorrhages  are  found  in 
addition  to  marked  degeneration.  The  lymph  nodes  are  usually  swollen 
and  contain  small  foci  of  cell-necrosis.  Broncho-pneumonia,  if  present, 
shows  the  usual  lesions  common  to  this  condition.  The  nervous  system, 
heart,  spleen,  lungs,  and  liver  show  the  most  destructive  effect  of  the  toxins 
of  diphtheria. 

Table  No.  75. — Tw>  hundred  anl  nine  cases  of  DiphtheH i  studied  h;j  Councilman,  Blallory, 

and  Pearce,  of  Boston,  in  1901,  showing  the  percentnge  of  cases  in  which 

th'i  different  bacteria  were  found  hi/  cilture 


Heart's  Blood. 

Liver. 

Spleen. 

Kidney  . 

Diphtheria  Bacillus       .    . 

Streptococcus  ....    

Staphylococc-us  Aureus     .    .    . 
Pneumococcus    .    .            .... 

6    per  cent 
20          " 

2.5       '' 
l'.5       " 

20  per  cent. 
31)         " 
4 

2  5     " 

12   per  cent. 
27 

3 

1.5       " 

19   percent. 

28 

8          " 
5 

The  Blood. — John  S.  Billings,  Jr.,^  says:— 

1.  The  red  corpuscles  of  the  blood  in  diplitlieria  undergo  a  diiuinu- 
tion  in  number  in  cases  of  moderate  severity  and  in  severe  cases.  Eegen- 
eration  is  slow. 

2.  The  leucocytes  are  increased  in  numl)ers  in  all  but  two  classes  of 
cases,  exceptionally  mild  cases  and  exceptionally  severe  ones.  As  a  rule, 
the  amount  of  leucocytosis  is  directly  proportionate  to  the  degree  of  severity 
of  the  case.  The  leucocyte-curve  shows  no  correspondence  to  the  clinical 
course  of  the  disease.  The  number  of  leucocytes  often  remains  higher  than 
normal  for  days  after  all  inflammation  has  disappeared.  The  leucocytosis 
is  similar  in  character  to  that  seen  in  pneumonia  and  scarlet  fever,  the 
increase  of  the  leucocytes  being  in  the  so-called  polynuclear  forms. 


'  Annual  Keport,  Health  Dopai  tnicnt,  lHf)7. 


DIPHTHERIA.  549 

3.  The  percentage  of  ligemogiobin  falls  coiucidently  with  the  niimber 
of  the  red  blood-corpuscles,  and  to  the  same  relative  degree.  But  the 
regeneration  of  the  liEemoglobin  takes  place  much  more  slowly  than  that 
of  the  red  blood-corpuscles. 

4.  In  cases  treated  with  antitoxin  the  diminution  in  the  number  of 
the  red  corpuscles  is  much  less  marked  than  in  those  cases  treated  without 
it ;  in  a  majority  of  cases  no  such  diminution  takes  place.  The  leucocytes 
are  apparently  unaffected  by  the  antitoxin.  The  haemoglobin  is  also  much 
less  affected  in  the  cases  treated  with  antitoxin,  thus  confirming  the  state- 
ment as  to  the  red  corpuscles. 

5.  In  healthy  individuals  injected  with  antitoxin,  the  red  corpuscles 
show  a  very  moderate  reduction  in  number  in  about  one-half  the  cases. 
The  haemoglobin  is  correspondingly  affected.  The  leucocytes  are  apparently 
unaffected  by  the  injections. 

6.  No  peculiar  characteristic  changes  in  the  morphology  of  the  cor- 
puscles were  to  be  made  out. 

7.  It  is  improbable  that  any  information  of  prognostic  importance  is 
to  be  gained  by  the  examination  of  blood  in  diphtheria. 

8.  The  antitoxin  treatment  of  diphtheria  has  no  deleterious  effects 
upon  the  blood-corpuscles.  On  the  contrary,  it  seems  to  prevent  degenera- 
tive changes  which  would  otherwise  l)c  brought  about. 

The  Effect  of  Diphtheria  Toxin  on  the  Nervous  System. — E.  Luisada 
and  D.  Pacchioni^  report  the  results  of  a  number  of  experiments  with  diph- 
theria toxin  on  dogs : — 

1.  The  diphtheria  toxins  applied  directly  to  the  nervous  system  pro- 
voke a  profound  lesion  at  the  point  of  application,  characterized  by  an 
inflammatory  and  degenerative  action. 

2.  These  lesions  are  propagated  more  or  less  extensively  from  the 
point  of  application. 

3.  In  nou-iinmunized  dogs,  which  had  lieen  injected  with  a  dose  suffi- 
ciently toxic,  tlie  ])]ien()niena  of  local  reaction  were  noted. 

4.  in  imiminizod  dogs  the  toxins  constantly  produced  alterations  in 
the  central  nervous  system,  intense,  localized,  but  of  less  extent  than  those 
produced  in  dogs  non-iinnumized. 

5.  The  toxin  applied  directly  to  the  medulla  is  propagated  rapidly  in 
all  directions,  preferriiig  the  })Osterior  columns,  the  gray  nuitter,  and  the 
central  canal,  as  routes.  In  consecpience  of  the  bulbar  invasion  death 
occurred  in  the  aiiim.ils  more  rapidly  when  the  toxins  were  introduced  into 
the  medulla  than  when  a])plied  to  any  otlier  ])ortion  of  the  cerebro-spinal 
axis.  When  the  toxins  were  introduced  into  the  cerebral  cortex,  character- 
istic lesions  of  these  regions  were  maiiirested.  Death  occurred  later  through 
propagation  of  the  po'son  1o  llie  medulla. 

'  Oiornalo  dcllii   11.  AccMiliMiiin  ili   Mcilicina   di  Tdiiiio,  vol.  Ixi. 


550  THE   INFECTIOUS   DISEASES. 

G.  Toxins  introduced  into  the  ylieath  of  tlie  sciatic  nerve  provoked  an 
inflammatory  process  more  or  less  intense,  but  more  circumscribed  than  in 
tlie  central  nt'rvous  system.  From  the-  nerves  the  poison  ascended  to  the 
medulla,  chiefl}'  through  the  posterior  columns,  and  thus  provoked  an  as- 
cendijig  myelitis. 

7.  The  lesions  produced  upon  theneurogliaby  direct  action  of  the  toxins 
are  similar  to  those  reported  by  Vassale,  Ponaggio,  and  others  in  the  various 
intoxications  and  infective  processes.  In  the  oblongata  the  prevalent  alter- 
ations are  found  in  the  crossed  pyramidal  tracts  and  posterior  columns. 

8.^  The  alterations  produced  by  the  toxins  aifect  the  nerve  fibers  more 
than  any  other  part  of  the  nervous  t'ssue.  These  lesions  affect  principally 
the  myelin,  and  consist  of  a  physical  modification  of  it,  whereby  the  con- 
nections between  the  various  nerves  are  lost.  There  is  partially  a  chemical 
modification  of  the  mj^elin  also  present. 

9.  The  local  action  of  the  toxins  has  much  importance  in  the  genesis 
of  various  paralyses  as  seen  in  the  human  family,  attacking  first  the  sheaths 
of  the  nerves,  then  the  nerves,  and  later  the  nerve  centers  of  the  medulla. 

Action  of  Diphtheria  Poison  on  the  Heart. — F.  Eolly,  first  as- 
sistant to  the  children's  clinic  at  Heidelberg,  as  the  result  of  a  series  of 
experiments  on  animals  with  the  diphtheria  toxin,^  concludes  that: — 

1.  The  fall  in  blood-pressure  induced  by  the  poison  of  diphtheria  is 
due  to  paralysis  of  the  vasomotor  center,  and  also  to  the  paralysis  of  the 
heart,  which  in  spite  of  artificial  respiration  soon  ceases  to  beat, 

2.  This  action  on  the  heart  is  direct,  and  in  warm-blooded  animals  is 
independent  of  the  nervous  system. 

3.  The  paralysis  of  the  heart  develops  after  a  more  or  less  definite 
latent  per'od.  Direct  injection  of  the  diphtherial  poison  or  transfusion  of 
lethal  diphtherial  blood  interferes  with  the  action  of  the  isolated  normal 
rabbit's  heart  only  after  a  certain  latent  period. 

4.  On  the  other  hand,  the  action  of  the  poison  takes  place  at  the  same 
time,  even  if,  before  the  appearance  of  poisonous  symptoms  or  at  the  be- 
ginning of  such  toxic  action,  the  heart  is  washed  out  with  normal  blood. 

5.  This  jiroperty  possessed  by  the  diphtheria  po'son  of  action  on  the 
heart  leads  to  the  o])inion  that  the  poison  gradually  takes  hold  of  the  heart 
muscles,  and  is  seemingly  stored  up  there  until  its  complete  action  is  mani- 
fest; this  further  explains  the  continuance  of  functional  heart  disturbances 
after  many  of  the  acute  infect'ons. 

Symptoms  and  Course. — Considering  the  clinical  ])icture  of  this  dis- 
ease, the  following  classification  would  appear  most  plausible: — 

1.  Local  diplttheria  (mild). 

2.  Diphtheria  with   constitutional  symptoms   (severe). 

3.  Septic  diphtheria  (usually  fatal). 

^"Archiv  filr  experimentelle  Pathologic  u.  Pharniakologie,"  42,  1899. 


DIPHTHERIA.  551 

Local  diphtheria  usually  commences  with  symptoms  of  malaise.  The 
appetite  is  poor;  the  tongue  is  coated,  and  the  lymph  glands  at  both  sides 
of  the  jaw  are  swollen.  The  pharynx  is  reddened.  The  mucous  membrane 
is  swollen  and  the  tonsils  are  covered  with  small,  grayish  yellow  plaques, 
which  adhere  very  firmly.  On  attempting  to  remove  a  piece  of  membrane 
a  bleeding  surface  remains.  This  membrane  peels  off  gradual'y,  but  leaves 
a  red  line  of  demarcation  on  the  tonsils.  •  A  close  study  of  the  tonsil  will 
show  the  former  size  of  this  pseudo-membrane.  Usually  the  color  of  the 
pbaryrx  returns  to  normal;  sometimes  it  is  rather  anaemic,  and  after  a 
few  days  the  scar  will  show  the  presence  of  the  former  affection.  When, 
however,  this  condition  does  not  resolve  in  a  few  days,  then  there  is  always 
danger  of  a  systemic  infection.  A  small  apparently  innocent  patch  on 
the  tonsil  or  pharynx  should  be  as  vigorously  treated  as  a  general  septic 
infection.  In  other  words  the  danger  of  a  small  patch  extending  to  the 
larynx  should  not  be  forgotten.  Other  forms  of  local  affections  are: 
Sometimes  the  lips  or  the  nose,  the  mucous  membrane  of  the  mouth, 
the  tongue,  the  vagina,  or  the  skin  are  the  seat  of  a  diphtheritic  infection. 
Not  infrequently  diphtheria  affects  the  umbilicus.  Such  diphtheritic 
omphalitis  is  exceedir.gly  dangerous  and  frequently  fatal.  Khinitis,  espe- 
cially in  young  infants,  is  frequently  a  diphtheritic  process,  although  re- 
sembling an  ordinary  "cold  in  the  head."  The  sudden  appearance  of  croup 
will  freqrently  cause  a  fatal  termination  if  neglected. 

Diphtheria  with  Constitutional  Sj/mptoms. — This  condition  usually 
commences  with  fever.  The  temperature  varies  between  101"^  to  102° 
F.  ]f  children  are  old  eiiough  they  will  complain  of  chills.  It  is  not 
uncommon  to  have  convulsiors.  The  cheeks  are  usually  flushed,  in  some 
instances  they  are  very  pale.  The  mucous  membrane  of  the  mouth  is  red- 
dened. The  pharynx  has  a  dark  red  color.  The  tonsils  are  swollen.  Both 
tonsils  are  intensely  congested  and  covered  with  a  yellowish  or  yellowish- 
gray  membrane.  The  uvula  is  usually  involved.  There  is  pain  on  swallowing 
and  a  decided  nasal  tone  of  voice.  The  submaxillary  glands  are  swollen. 
The  nose  discharges  an  acrid  fluid  containing  yellowish  shreds  or  flakes.  In 
many  cases  after  careful  treatment  the  appetite  returns.  The  diphtheritic 
patches  are  limited  in  area.  The  intense  swelling  and  congestion  fades. 
The  mucous  membrane  appears  and  the  swelling  of  the  submaxillary  glands 
subsides,  so  that  conditions  resume  their  normal  state.  On  the  other  hand 
the  affection  may  spread  from  the  ])harynx  and  involve  the  velum  palatinuni 
and  extend  downward  so  that  the  larynx  is  involved,  causing  stenosis  and 
other  serious  symptoms. 

Nasal  Diphtheria. — A\'hen  the  local  ail'ection  is  confined  to  the  nose, 
the  outlook  is  not  good.  It  is  important  to  remember  that  no  form  of 
diphtheria  is  more  fatal  than  the  nasal  variety. 


552 


THE   INFECTIOUS   DISEASES. 


When  there  is  a  general  infection,  then  greater  attention  should  be 
2}aicl  to  the  condition  of  the  heart.  The  pulse  is  usually  small  and  thready. 
Tlie  heart  sounds  are  feeble;  sometimes  they  are  muffled.  In  other  in- 
stances there  is  a  tachycardia.  The  extremities  are  usually  cold.  If  these 
symptoms  do  not  subside,  and  the  affection  spreads,  then  there  may  be  later 
a  total  absence  of  the  patellar  reflexes.  There  may  also  be  vomiting,  a 
decided  apathetic  condition,  and  a  slowing  of  the  heart's  action  (brady- 
cardia). 


Oct. 

15 

16 

17 

IS 

19 

20 

21 

23 

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Fig.  167. — Case  of  Nasal  Diplithcria.  George  P.  Willard  Parker  Hos- 
pital. Iiijeeted  with  3000  units  of  antitoxin  on  the  ir)tli,  and  5000  on  the 
ITth.     (Original.) 

(ieorge  P.,— age  Ty,  years,  admitted  to  the  Willard  Parker  Hospital  Oct.  15;  ill 
two  days.  General  condition,  fair.  No  pseudo-nienibrane  was  visible  in  the  throat. 
The  cervical  glands  were  very  much  enlarged.  There  was  a  serosanguineous  discharge 
from  the  nose;  besides,  the  entrance  to  the  nostrils  appeared  angry  and  excoriated. 
Bacteriological  examination  showed  Klebs-Loeffler  bacilli.  Patient  was  allowed  out 
of  bed  October  22. 

The  liver  is  usually  very  much  enlarged  and  feels  very  hard  on  palpa- 
tion. In  other  cases  there  will  be  marked  diminution  in  the  quantity  of 
urine.  When  urine  is  scanty  and  contains  casts  and  blood,  showing  a  dif- 
fuse nephritis,  then  it  is  not  rare  to  find  convulsions  of  a  uraemic  character. 


DIPHTHERIA. 


553 


resulting  fatally.  The  sudden  appearance  of  diarrhoea  is  frequently  a  very 
serious  symptom,  resulting  in  collapse  and  ending  fatally. 

In  other  instances  continuous  crying  may  be  the  forerunner  of  earache 
resulting  in  suppuration.  Xot  infrequently  moist  rales  and  bronchial 
breathing  show  evidences  of  broncho-pneumonic  areas  in  the  lungs,  so  that 
the  general  infection  of  a  child  with  diphtheria  should  be  dreaded,  owing  to 
the  danger  of  complications  associating  themselves  with  the  primary  con- 
dition. 

Septic  Diphtheria. — Frequently  a  pharyngeal  affection  in  septic 
diphtheria  will  assume  a  decided  gangrenous  character.    If  this  gangren- 


19C3. 

DATES  OF  OBSERVATIONS                                       | 

vW.. 

6 

7 

8 

9 

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n 

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per  minute 

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per  mtnute 

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Fig.  168. — Septic  Type  of  Diphtheria  Complicated  by  ]\Iyocai (litis. 
The  efTect  of  tlie  poison  is  shown  on  tlie  lieart.  Note  the  pulse-rate,  low 
temperature  and  the  respiration.     (Original.) 


ous  state  appears,  we  will  find  the  pharynx  to  be  the  scat  of  a  putrid, 
smeary  exudate  covering  the  tonsils  and  the  velum  palatinum.  From 
the  nose  a  sanious,  foul-smelling  discharge  exudes.  The  lips  appear  chapped 
and  bloody.  The  tongue  is  shining  and  dry.  The  submaxillary  glands  arc 
very  much  swollen.  The  ch'ldren  apjiear  ]iufFed,  and  tlie  face  lias  a  pale, 
waxy  appearance.  '^Plie  exlreiiiities  are  cool.  The  lieart  sounds  are  weak, 
sometimes  inaudible.  The  pulse  is  small,  sometinies  thready,  and  can  be 
counted  with  difFiculty.  There  is  severe  constipation,  rarely  diarrluei. 
The  brain  is  clear,  although  tlie  children  appear  in  a  seini-eoinatose  con- 
dition, moaning  and  with  mouth  ojx'ii.     Tlie  ur'iiie  is  (liininished  and  con- 


554 


THE  INFECTIOUS  DISEASES. 


taius  albumin  and  also  epithelium.  There  is  a  general  apathetic  condition, 
and  the  cardiac  weakness  increases  until  the  fatal  termination.  In  other 
instances  there  is  a  decided  hannorrhagic  tendency.  Hsemorrhagic  spots 
appear  on  tlie  skin.     The  urine  is  bloody.     The  stools  contain  blood. 

Epistaxis  is  frequent.  There  is  a  general  somnolence.  A  tendency  to 
collapse,  ending  fatally. 

Follicular  Forms  of  Diphtheria. 

We  are  frequently  called  to  see  children  having  follicular  tonsillitis. 
Such  children  should  be  isolated,  and  treated  as  though  we  were  dealing 
with  true  diphtheria.  Ever)'  follicular  inflammation  in  the  tonsil  should 
be  looked  upon  with  suspicion.     It  is  necessary  to  take  a  culture  to  see  if 


1<)0Z- 

JTUNE                   DATES  OF  OBSERVATIONS                                                                                        | 

May 

26 

27 

28 

29 

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31 

1 

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6 

7 

8 

9 

10 

11 

12 

13 

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Fig.  169. — Broncho-pneumonia  Complicating  Diphtheria.  Antitoxin 
rash  scarlatinal  in  character  appeared  four  days  after  injection.  Second 
eruption  appeared  ten  days  later.  Note  peculiarity  of  temperature  curve. 
Severe  croup  required  intubation.  Child  remained  well  for  thirty-two  days 
after  second  intubation,  then  severe  croup  appeared  and  required  intubation. 
In  all  seven  intubations  were  required.    Child  discharged  cured.     (Original.) 

the  Klebs-Loeffler  bacilli  arc  present.  It  is  well  to  remember  that  diph- 
theria frequently  manifests  itself  in  the  form  of  a  follicular  infection  in 
which  the  disease  is  confined  to  the  lacunae  of  the  tonsil.  (See  colored 
illustration.) 

When  the  disease  is  confined  to  the  crypts  or  follicles  of  the  tonsils, 
then,  clinically,  this  diphtheritic  infection  resembles  that  form  of  non- 
diphtheritic  tonsillitis  which  is  commonly  called  quinsy. 


I'LATE  XVI 

Case  A. — Common  Type  of  Diphtheria.  Child  three  years  old.  Seen 
on  fourth  day  of  illness  at  the  Willard  Parker  Hospital.  Exudate  covering 
tonsils,  pharynx,  and  uvula.  Keceived  in  all  16,000  units  of  antitoxin. 
Throat  clear  on  sixth  day.     Case  discharged  cured.      (Original.) 


Case  B. — Follicular  Type  of  Diphtheria.  Child  seven  years  old. 
Seen  on  second  day  of  illness  at  the  Willard  Parker  Hospital.  The  mem- 
brane involved  the  lacunae  of  the  tonsils.  Note  the  close  resemblance  to 
follicular  tonsillitis.     Received  in  all  6,000  units  of  antitoxin.       (Original.) 


Case  C. — Hemorrhagic  Type  of  Diphtheria.  Child  seven  and  one- 
half  years  old.  Seen  on  sixth  day  of  illness  at  the  Willard  Parker  Hospital. 
Tonsillar  and  postpharyngeal  exudate.  Severe  nasal  and  postpharyngeal 
haemorrhages  during  exfoliation  of  membrane.  Received  in  all  15,000  units 
of  antitoxin.  Throat  clear  on  ninth  day  of  illness.  Myocarditis  developed. 
Case  discharged  cured  four  weeks  after  admission.      (Original.) 


Case  D. — Septic  Type  of  Diphtheria.  Child  eight  years  old.  Seen 
on  the  fifth  day  of  illness  at  the  Willard  Parker  Hospital.  The  pseudo- 
membrane  in  this  case  covered  the  hard  palate  and  extended  in  one  large 
mass  down  the  pharynx,  completely  hiding  the  tonsils.      (Original.) 


PLATE  XVI 


DIPHTHERIA. 


555 


Whether  diphtheria  affects  the  jjharynx,  the  larynx,  or  the  crypts  of 
the  tonsils,  the  disease  is  diphtheria,  and  the  treatment  should  be  aimed 
at  limiting  the  disease  to  prevent  toxsemic  conditions  and  complications. 

Basil  es. — Very  frequently  rashes  follow  the  injection  of  antitoxin. 
These  rashes  are  of  an  erythematous  character:  — 

(a)    Scarlatiniform.  (1))    Morbilliform.  (c)   Urticarial. 

In  a  report  made  by  the  Investigating  Committee  of  the  Clinical 
Society  of  London,  of  633  cases,  there  were  rashes  in  220,  or  34.7 
per  cent.     Of  these  the  rash  vas: — 

Erythematous    101 

Urticarial    37 

Mixed 17 

Petechial .  5 

The  following  series  of  cases  were  noted  by  Dr.  Burckhalter  at  the 
Willard  Parker  Hospital  during  my  service: — 


Table  No.  76. 


April,  1903 

May,  1903 

June,  1903 

July,  1903 

Total  Cases     .    .    .117 

Total  Cases  .    .130 

Total  Cases        131 

Total  Cases  .    .    .101 

Died                 ...    29 

Died.            .    .    29 

Died.    .        .    .    25 

Died       17 

Discharged  ....      0 

Discharged     .    .    9 

Discharged      ,12 

Discharged   ...    15 
Transfd  i  .    .    ,    .      2 
Tracheotomy  .    .        1 

Total  Tube  Cases,  35 

Total  Tube  Cases,  38 

Total  Tube  Cases,  37 

Total  Tube  Cases,  34 

No.  of 

Days  After 

No.  of 

Davs  Af  ei 

No.  of 

Days  After 

No.  of 

Days  After 

Rashes. 

Injection. 

Rashes. 

Injection.   | 

Rashes. 

Injection. 

Rashes. 

Injection. 

8 

2 

0 

2 

18 

2 

1 

20minutes 

8 

3 

11 

3 

10 

3 

1 

6  hours 

1 

4 

5 

4 

3 

4 

10 

2  day , 

4 

5 

4 

5 

4 

5 

6 

3     •' 

1 

0 

2 

0 

1 

7 

5 

4     " 

2 

7 

1 

7 

1 

8 

3 

5     " 

2 

8 

1 

8 

2 

9 

4 

0     " 

2 

10 

2 

10 

2 

11 

1 

8     " 

1 

12 

18 
19 
20 

1 
1 
1 
1 

1 
1 

11 
12 
14 
15 
19 
20 

2 

1 

'  9     " 

1 
1 

41  Rashed 

10     ' 

1 

34  Rashes 

32  Rashes 

38  Rashes 

Largest  Number, 

Largest  Number,    ' 

Largest  Number, 

Largest  Number, 

8  each  on  2d 

and  3d  Days 

11  on  i 

kl  Day       i 

18  on  J 

MDay 

10  on 

2d  Day 

Total  Number  of  Cases,  479.     Total  Rashes,  145^:32.08%. 

'  TransTerred  to  Riverside  Hospital,  New  York. 


556  THE   INFECTIOUS  DISEASES. 

C.  Hartung  quotes  a  number  of  European  observers  who  found  an 
antitoxin  rash  in  11.4  per  cent,  out  of  2GG1  cases.  Berg  found  the  rash 
in  82  cases  out  of  337  or  24  per  cent.  This  condition  is  described  in  detail 
m  Xothnagel's  Encyclopedia,  pages  153-1G2. 

While  Ncrthrup  reports  147  cases  of  rash  occurring  between  1  he  seventh 
and  twelfth  day,  other  observers  report  the  rash  as  occurring  much  earlier. 
In  the  series  above  reported  the  largest  number  of  rashes  occurred  on  the 
second  and  third  day  after  the  injection.  I  have  frequently  seen  an  anti- 
toxin rash  several  hours  after  the  injection  was  given,  while  the  majority 
of  rashes  were  fully  developed  on  the  second  day. 

The  following  case  illustrates  the  rapidity  with  which  a  rash  may 
appear : — 

Laurence  S.,  aged  4  years.  Admitted  September  8,  1903,  to  the  Willard  Parker 
Hospital,  on  the  third  day  of  illness.  He  was  in  a  poor  condition  when  admitted. 
He  was  intubated  about  one-half  hour  before  being  admitted  to  the  hospital.  Slight 
retraction  present.      Membranes  on  right  tonsil.      Profuse  nasal  discharge. 

The  physical  examination  was  negative.  The  heart  regular  and  of  good  force; 
4000  units  of  antitoxin,  of  serum  (horse)  220,  were  given  when  admitted.  There  was 
no  rash  present  when  the  antitoxin  was  injected.  Seven  minutes  after  the  antitoxin 
injection  the  patient  had  a  profuse  rash  all  over  the  chest,  extending  from  the  fifth 
ribs  to  clavicles.  The  rash  and  flush  were  most  marked  in  the  area  coiTesponding 
to  the  place  of  injection.  The  tongue  was  heavily  coated.  Could  not  take  much 
nourishment.    Grew^  gradually  worse.    Died  September  9th. 

Site  of  the  Eruption. — A  large  flush  is  frequently  seen  on  the  parts 
around  the  point  of  injection,  from  whence  it  spreads  over  the  body.  It  is 
most  frequently  seen,  however,  on  the  abdomen,  chest,  and  buttocks;  less 
frequently  at  the  wrists,  knees,  and  ankles.  The  face  and  neck  are  seldom 
involved.  It  sometimes  covers  the  back  as  well  as  the  buttocks.  There  is 
intense  itching  and  occasionally  the  children  complain  of  intense  pain  in 
the  joints. 

Fever  usually  precedes  the  eruption. 

Constitutional  symptoms,  such  as  vomiting,  diarrhoea,  headache,  mus- 
cular pains,  and  general  malaise  are  noted.  Not  infrequently  when  liyper- 
pyrexia  exists  there  is  delirium  or  convulsions  (Sevestre  and  Martin). 

Desquamation. — A  very  fine  mealy  desquamation  follows  the  anti- 
toxin rash.  It  is  similar  to  the  measles  desquamation  (Berg).  A  rash  re- 
sembling measles  never  has  the  catarrhal  symptoms  which  we  always  note 
in  genuine  measles.  If,  however,  we  are  in  doubt  regarding  the  true  nature 
of  the  rash,  it  is  well  to  isolate  and  await  results  rather  than  to  expose 
children  to  the  risk  of  infection. 

Diagnosis. — The  diagnosis  of  diphtheria  affecting  the  pharynx,  ton- 
sils, and  nares  with  visible  membranes  is  (juite  easily  made.  When,  how- 
ever, the  disease  affects  the  lower  respiratory  tract,  the  larynx,  trachea,  or 
bronchi,  the  diagnosis  will  be  rendered  more  difficult.    The  crucial  test  con- 


PLATE  XVII 


Lizzie  F.,  5  years  old,  was  admitted  to  the  Willard  Tarker  Hospital  in 
September,  1904.  She  was  ill  seven  days  before  admission.  Diphtheria  was 
present  on  both  tonsils.  There  was  slight  glandular  swelling.  The  general 
systemic  condition  was  poor.  The  temperature  was  101°  F.,  pulse  120, 
respiration  24.  The  child  received  5000  units  of  antitoxin  on  admission, 
and  on  the  following  day  a  second  injection  of  4000  units.  Four  days  after 
the  second  injection  of  antitoxin,  the  throat  cleared  so  that  no  membrane 
was  visible.  Two  days  later,  or  six  days  after  the  second  antitoxin  injec- 
tion, a  universal  rash  appeared  on  the  face,  chest,  abdomen,  back,  and  ex- 
tremities. This  rash  was  morbilliform  in  character  and  persisted  for 
twenty-two  days,  although  it  was  chiefly  confined  to  the  arms  and  logs.  No 
complications  followed.  The  child  left  the  hospital  in  excellent  condition. 
(Original.) 


DIPHTHERIA.  557 

sists  in  taking  a  culture  and  noting  the  bacteriological  result.  The  presence 
of  the  Klebs-Loeffler  bacillus  means  diphtheria. 

We  must  not  infer  that  if  the  Klebs-Loeffler  bacillus  is  not  found  that 
our  case  is  of  a  non-diphtheritic  character.  A  technical  error,  such  as 
swabbing  a  healthy  surface  instead  of  an  infected  area,  may  be  the  cause  of 
a  negative  result.  Not  infrequently  in  ttte-most  malignant  forms  of  diph- 
theria, nothing  hut  a  streptococcus  can  he  found.  This  is  especially  true 
when  complications  such  as  hroncho-pneumonia  are  met  with. 

Bacteriological  Diagnosis. — Directions  for  Inoculating  Culture  Tubes 
with  the  Exudate  in  Cases  of  Suspected  Diphtheria:  The  child  should  be 
placed  in  a  good  light,  and  properly  held,  Eemove  the  swab  from  its  tube. 
Depress  the  tongue  with  a  spoon  in  the  bft  hand.  With  the  swab  in  the 
right  hand  rub  firmly  but  gently  against  any  visible  membrane  on  the  ton- 
sils or  in  the  pharynx.  Withdraw  the  cotton  plug  from  the  culture  tube. 
Insert  the  swab,  and  rub  it  thoroughly  but  gently  back  and  forth  over  the 
entire  surface  of  the  blood  serum.  Do  not  allow  the  swab  to  touch  any- 
tliing  except  the  throat  of  the  patient  and  the  surface  of  the  serum.  Do 
not  push  the  swab  into  the  serum  or  break  the  surface  in  any  way.  Ee- 
place  the  swab  in  its  own  tube ;  plug  both  tubes ;  fill  out  the  blank  forms 
which  accompany  each  tube,  and  send  to  a  culture  station.^ 

If  there  is  no  visible  membrane  (it  may  l)e  present  in  the  nose  or 
pharynx)  the  swab  should  be  thoroughly  rubbed  over  the  mucous  membrane 
of  the  pharynx  and  tonsils,  and  in  nasal  cases,  when  possible,  a  culture 
sliould  also  l)e  made  from  the  nose.  In  little  children  care  should  be  taken 
not  to  use  the  swab  when  the  throat  contains  food  or  vomited  matter,  as  then 
the  bacterial  examination  is  rendered  more  difficult.  lender  no  considera- 
tion should  any  attempt  be  made  to  collect  the  material  shortly  after  the 
application  of  disinfectants  (especially  solutions  of  corrosive  sublimate)  to 
the  throat.  If  any  of  these  instructions  have  not  been  carried  out  tlie  fact 
sliould  l)e  carefully  noted  on  the  record  blank. 

Welch  says:  "The  mere  presence  of  the  diphtheria  bacilli  in  the  throat 
of  a  patient  no  more  proves  that  he  has  diphtheria  then  the  presence  of  t'  e 
pneumococcus  in  his  saliva  establishes  the  fact  that  he  has  pneumonia.  The 
only  decisive  method,  as  claimed  with  much  justice  by  liunge,  is  control 
experiments  in  the  way  of  animal  inoculations." 

If  a  croupy  cough  is  heard  and  associated  with  it  a  small  diphtheritic 
membrane  is  seen  on  the  tonsils,  pharynx,  or  in  the  nose,  the  diagnosis  of 
diplitheria  can  ])ositively  ])e  made. 


'  The  New  York  Department  of  Health  has  a  series  of  eiilture  stations  in 
various  drug  stores.  At  these  stations  sterile  culture  tubes  are  supplied  to  the 
physician  and  the  same  are  also  collecled  daily  after  inoculation.  The  Depart- 
ment of  Health  furnishes  material,  including,'  examination  and  report,  free  of  charj^e. 


558  THE   INFECTIOUS  DISEASES. 

Differential  Diagnosis.— In  the  very  beginning  of  the  disease,  before 
the  appearance  of  a  pseudo-membrane,  the  diagnosis  is  beset  with  difficulty. 
Thus,  an  acute  catarrhal  angina  will  show  symptoms  similar  to  those  of 
diphtheria. 

Pre-membranous  Stage. — If  seen  early  the  throat  is  usually  intensely 
congested  and  reddened.  It  may  be  a  day  or  two  before  the  membrane  will 
be  visible.  The  disease  is,  primarily,  a  local  disease.  The  systemic  infec- 
tion which  accompanies  the  same  is  due  to  the  absorption  of  the  toxins 
thrown  out  by  the  micro-organ  sms  present  in  these  pseudo-membranes. 

Thrush  sometimes  resembles  diphtheria,  but  can  be  differentiated  by 
the  fact  that  the  small  whitish  spots  resembling  curdled  milk  are  scattered 
over  the  cheeks,  lips,  tongue,  and  gums,  in  addition  to  the  uvula  and 
pharynx. 

Ulcerative  tonsillitis^  resembling  diphtheria  has  been  described  by  Vin- 
cent. In  this  condition  there  is  no  tendency  to  spread.  There  is  an  absence 
of  croup,  and  a  culture  taken  shows  the  Vincent  bacillus  instead  of  the 
Klebs-Loeffler  bacillus. 

Peritonsillar  Abscess. — In  this  condition  we  meet  with  a  swelling  or 
bulging  forward  of  the  affected  parts.  The  uvula  is  sometimes  displaced. 
There  are  very  many  active  local  symptoms,  such  as  pain  and  difficulty 
in  swallowing,  and  a  nasal  tone  of  voice.  Not  infrequently  when  an  at- 
tempt to  swallow  is  made  the  fluid  regurgitates  through  the  nose.  When 
children  are  old  enough  to  describe  subjective  symptoms,  they  will  complain 
of  chills  and  fever.  The  temperature  is  usually  high,  ranging  from  103°  to 
105°  F.  The  active  symptoms  subside  the  moment  pus  is  relieved.  Nature 
frequently  gives  a  spontaneous  evacuation  of  the  pus.  At  other  times  it  is 
wiser  to  give  relief  by  making  an  incision  and  emptying  the  pus.  A  culture 
taken  in  this  condition  does  not  show  the  presence  of  the  Klebs-Loeffler 
bacillus. 

Follicular  Tonsillitis. — In  this  condition  more  than  in  any  other  form 
of  disease  ive  must  be  careful  regarding  a  positive  opinion.  There  are 
follicular  forms  of  diphtheria  involving  the  lacunce  of  the  tonsils  vhich 
rlinically  so  resemble  diphtheria  that  even  an  expert  cannot  differentiate 
them. 

The  clinical  manifestations  of  the  benign  form  of  follicular  tonsillitis 
have  already  been  described  in  the  article  on  "Follicular  Tonsillitis." 

The  differential  diagnosis  depends  on  the  presence  or  absence  of  the 
Klel)s-Loeffler  liacillus. 

Complications.- — The  most  frequent  complication  met  with  is  broncho- 
pneumonia.    More  deaths  occur  from  this  than  from  any  other  complica- 


^Read  article  on  "Tonsillitis." 

*  For  a  detailed  description  of  the  various  complications,  the  reader  is  referred 
to  the  special  chapters  on  "Otitis,"  "Empyema,"  etc. 


DIPHTHERIA. 


559 


tion.  It  is  usually  the  extension  of  the  disease  from  the  lar3'nx  to  the 
bronchi.  When  a  septic  form  of  diphtheria  exists  broncho-pneumonia  usu- 
ally accompanies  it.      (See  chapter  on  "Pneumonia.") 

Pleurisy  with  serous  effusion  frequently  comjilicates  this  disease. 

Empyema  not  infrequent^'  complicates.  A  number  of  these  cases  have 
been  seen  by  me  during  my  service  at  the  Willard  Parker  Hospital. 

Otitis  is  occasionally  met  with  as  a  complication  of  diphtheria.  It  is 
usually  the  result  of  a  streptococcus  infection  through  the  nose  or  throat 
into  the  Eustachian  tube. 

Myocarditis  is  the  most  frecjuent  form  of  heart  complication  met  with 
in   diphtheria. 

Endocarditis  and  pericarditis  are  also  seen  in  severe  types  of  this 
disease. 


Fig.  170. — Pmiimonia  Complicating  Dijilithcria.  (Kind  assistance  of 
Dr.  Edward  H.  Sparkman,  Jr.,  at  the  Willard  Parker  Hospital.)  A.— Start- 
ing point  of  pneumonia  showing  extent  on  third  day.  B. — Focus  which 
developed  three  days  after  (A)  showing  extent  on  third  day  of  the  new 
focus.     (Original.) 

Meningitis  is  not  often  seen,  though  I  have  seen  3  such  cases  out  of 
a  total  of  35  at  the  Willard  Parker  Hospital,  during  my  service.  About 
10  per  cent,  of  all  septic  cases  have  meningitis. 

•         Cerebral  tliromhosis  and  embolism  occasionally  complicate  diplithoria, 
and  result  in  hemiplegia,  convulsions,  or  aphasia. 

Thrombosis  of  the  pulmonary  artery  of  the  heart  may  cause  sudden 
death.  This  is  usually  accompanied  by  feeble  heart's  action,  the  result  of 
degenerative  changes  in  the  muscular  walls    (Holt). 

Jlcpmorrhagcs  occur  quite  often.  Bleeding  from  the  nose  and  from  the 
ear,  also  ])lood  in  the  urine  and  blood  in  the  stools  lias  fre(|iu'ntly  been  seen 
by  nie.     These  cases  are  of  the  most  severe  type  ar.d  usually  cud   fatally. 


560 


THE  INFECTIOUS  DISEASES. 


Purpuric  spots  similar  to  that  I'orin  ol'  [)iirpura  met  with  in  rlieuiuatism 
were  seen  by  me  in  septic  cases,  all  of  which  ended  fatally. 

KepJtritis^  is  usually  met  witli_in  septic  cases,  although  it  may  follow 
as  a  complication  of  the  milder  form  of  this  disease.  Traces  of  albumin 
are  frequently  found  during  the  course  of  diphtheria.  This  does  not 
necessarily  imply  that  we  are  dealing  with  nephritis.  The  presence  of  casts 
in  addition  to  the  albumin,  or  possibly  blood,  is  necessary  to  strengthen  the 
diagnosis  of  nephritis. 


190.S  . 

DATES  OF  OBSERVATIONS.                                            | 

6 

7 

8 

9 

10 

II 

12 

J3  14 

rs 

Cent. 

Fahr. 

kft'.m 

am:pm 

m'.m 

am:pm 

am:pm 

am:pm 

AMiPM 

AM^PM  AM>M 

AMiPM 

0  I 

40°" 

•6 
106° -2 

; 

•8 
•6 

101° -2 

■h 

A 

[^ 

39°" 
38°~ 

•8 

i03°-2 

• 

l\ 

'■/^ 

J 

r 

•8 

A 

A 

f^J 

■\ 

J 

^ 

^ 

•8 
•6 

•loi"-! 

7 

V 

'V 

^^ 

• 

-8 
•6 

100° -2 

• 

37  °~ 

•8 

•8 

-      »•♦ 

-90  -2 

•  8 
•6 

S6~ 

-9S'-2 

•8 

•c 

-         o"  i 

-97   -2 

■ 

•  8 

•e 
-96° -2 

- 

rulse 
per  minute 

'oloa 

Q|  f\^  S  <=3  ^^    C|f< 

^ 

5 

4 

^j^ 
v^'  ^ 

§. 

Iteapirationa 
per  mtnule 

c 

N!0 

ocj 

Fig.  171. — Temperature  Chart  from  a  Case  of  Diphtheria  complicated  by 
Broncho-pneumonia  (Step-ladder  Type  of  Fever).      (Original.) 


Diarrhoea  due  to  a  follicular  ileo-colitis  or  acute  gastric  catarrh  fre- 
quently complicates  diphtheria. 

Diphtheritic  Gastritis. — When  membranous  gastritis  occurs  it  is  usu- 
ally a  diphtheritic  gastritis. 

Diphtheritic  omphalitis  is  dcscril)ed  in  Chapter  ITT,  T*art  TT. 


'An  excellent  illustration  of  nephritis  complicating  diphtlicria  is  described  in 
the  article  on  "Neplu'itis." 


DIPHTHERIA. 


661 


When  membranous  enteritis  complicates  diphtheria  it  is  usually  the 
result  of  a  streptococcus  or  Klebs-Loeffler  iufection. 

Profound  anaemia  usually  follows  diphtheria.  This  is  due  to  the  effect 
of  the  toxins  in  the  blood  causing  the  destruction  of  the  red  corpuscles. 

Post-diphtheritic  Paralysis. — Toxa?mia  caused  by  absorption  of  the 
toxins  generated  by  the  Klebs-Loeffier  bacillus,  if  not  neutralized 
either  by  an  injection  of  antitoxin  or  by  Nature's  own  production 
of  antitoxin,  frequently  causes  paralysis.  This  paralysis  usually 
affects   individual    muscles    or   groups    of    muscles.     In    this    manner   the 


tJlQi- 

DATES  OF  OBSERVATIONS                                                            .J 

1 

2 

3 

4 

6 

6 

7 

8 

9 

10 

n 

Cent. 

Fakr 

«M>M 

*M 

PM 

AMiPM 

«m:pm 

kW.tU 

liU'.n 

AM.PH 

kUfU 

*m:(>m 

am:i>m|aii:pm| 

41°  ~ 
40°~ 

•106  ; 

•  • 

■/I 

il 

■] 

•loe"- 

i^^ 

.X 

h 

■P3 

0 

104°' 

i:| 

/^ 

j 

i| 

s 

'■■ 

fci 

39°" 

■103°- 

r 

•  • 

f 

\': 

H 

•A 

/' 

/ 

-102°- 

:/ 

4 

'■>, 

^/ 

/ 

•  ■ 

•  - 

38°" 

101°- 

V. 

■100°- 

37  °~ 

-90'' 

;      ; 

; 

36'" 

-9»  •  > 

-97°- 

V- 

Putte 
per  minriie 

1^ 
1^ 

■^^ 

ig 

5§ 

n 

3§ 

IS 

5! 

S3^ 
<?  ^ 

^ 

Rt^rattora 
per  minutt 

joe 

^? 

^"^ 

^^ 

^ 

Fig.  172. — Temperature  Chart  from  a  Case  of  Diplitheria  complicated  by 
Lobar  rneuinonia.      (Original.) 


heart,  which  is  a  muscular  organ,  is  frequently  paralyzed,  resulting 
in  dcatli.  When  tlie  toxin  affects  tlie  respiratory  centers  it  may 
result  in  paralysis,  causing  death  by  asphyxia.  In  addition  to  the  para- 
lytic effect  of  this  toxin  on  the  muscles  and  nerves,  degenerative  changes 
are  brought  about  by  the  influence  of  this  poison.  Thus  it  is  that  the  toxin 
in  the  system  will  frequently  irritate  an  otherwise  healthy  kidney  and  set 
up  a  toxic  nephritis. 


562 


THE  INFECTIOUS  DISEASES. 


From  the  foregoing  we  can  see  that  the  po'son  generated  by  the  Kleljs- 
Loeffler  bacillus  is  certainly  a  serious  factor  which  must  be  dealt  with  very 
energetically. 

A  study  of  recorded  cases  of  paralysis  shows  that  I)etween  10  and  30 
per  cent,  of  all  cases  of  diphtheria  are  followed  by  paralysis,     ^Yoodward 
studied    7832    cases   of   diphtheria ;    of   these    1362   had   post-diphtheritic 
paralysis.     Myers,  in  the  London  Lancet,  1900,  studied  1316  cases  of  the 
disease,  in  which  275  cases,  or  about  21  per  cent.,  had  palsy. 
110  cases  affected  the  palate, 
69  cases  were  cardiac, 
21  cases  diaphragmatic. 

Th.ere  are  four  palsies  due  to  severe  toxa?mia ;  they  occur  in  the  follow- 
ing order:  palatal,  ocular,  cardiac,  and  diaphragmatic. 


Fig.  173. — Temperature  Chart  from  a  Case  of  Diphtheria  complicated  by 
Otitis  and  Meningitis.     Fatal.     (Original.) 


Paralysis  is  most  frequently  found  in  (hildren  hetu'ee:i  the  second  and 
sixth  years.  Usually  during  the  second  week  following  diphtheria,  when 
the  child  is  convalescent,  emaciation  of  the  extremities  will  be  noticed.  If 
the  muscles  of  the  trunk  arc  involved,  there  will  be  emaciation  of  the 
thoracic  muscles,  regurgitation  of  liquids  through  the  nose,  and  a  nasal 
twang  in  the  voice.  There  is  marked  difficulty  in  walking  or  climbing 
stairs  in  other  cases;  the  child  waddles  and  appears  weak,  falls  easily,  and 
staggers  as  in  ataxia.  In  severe  cases  the  cliild  is  unalde  to  raise  its  head. 
The  sphincter  of  the  rectum  and  bladder  may  become  paralyzed,  resulting 
in  involuntary  urination  or  obstinate  constipation. 


DIPHTHERIA.  563 

Paralysis  of  the  extremities  may  be  added  to  paralysis  of  the  respira- 
tory muscles  or  of  the  heart.  The  knee-jerk  may  be  dimxinished  or  absent. 
The  al)sence  of  the  knee-jerk  indicates  some  change  in  the  peripheral  neu- 
ron. The  sperial  heart  sijinploms  indicating  cardiac  paralysis  are  irregu- 
larity of  heart's  action  or  a  gallop  rhythm,  bradycardia,  tachycardia,  lower- 
ing of  the  temperature  (usually  subnormal),  vomiting;  dilatation  of  the 
heart,  a  short  first  sound  with  systolic  murmur  at  apex,  l)lueness  of  the  lips, 
and  cold  extremities. 

''Monicatide  divided  diphtheritic  paralysis  into  four  groups :  Those 
showing  (1)  purely  muscular  change  without  nerve  involvement;  (2) 
polyneuritis;  (3)  lesions  of  the  spinal  cord,  which  were  either  localized  in 
the  gray  matter,  leading  to  atrophy  of  muscles,  or  involved  the  white  matter 
of  the  cord  in  a  similar  way  to  that  seen  in  locomotor  ataxia  or  multiple 
sclerosis,  and  (4)  cerebral  haemorrhage  chiefly  due  to  circulatory  change. 
This  classificat'on  is  acce^^ted  by  many  of  to-day.  To  be  scientifically  cor- 
rect, however,  the  fourth  group,  i.e.,  the  cerebral  palsies,  should  not  be 
classed  as  a  pa'sy  due  to  a  diphtheritic  toxin,  iuasamch  as  they  are  acci- 
dental. Strictly  speaking  the  term  diphtheritic  palsy  should  be  applied  to 
those  palsies  only  which  are  due  to  direct  action  of  the  diphtheritic  toxin." 

A  childj  4  years  old,  was  seen  during  my  service  at  the  Willavd  Parker  Hos- 
pital. He  had  suffered  with  severe  tonsillar  and  pharyngeal  diphtheria.  The 
exudate  was  unusually  thick.  The  resident  physician  called  my  attention  to  a 
r<  ^.urgitation  of  the  licjuids  through  the  nose  and  to  the  nasal  twang  in  speaking. 
On  examining  the  throat,  all  evidences  of  diphtheria  had  disappeared.  The  tip  of 
the  uvula,  instead  of  hanging  in  the  median  line,  pointed  toward  the  left  side.  As 
this  case  was  a  severe  type  of  diphtheria  we  were  not  sui-prised  to  see  the  paralysis. 
Strychnine  was  given.    The  case  recovered. 

"\Mien  diphtheria  has  preceded  an  attack  of  paralysis,  the  diagnosis 
is  easily  made.  Emaciation  is  general  as  a  rule  and  not  confined  to  a  sim- 
ple grouj)  of  muscles. 

Tlie  disease  is  sometimes  mistaken  for  acute  anterior  poliomyelitis. 
The  onset  of  the  latter  is  sudden  and  is  usually  preceded  by  fever.  The 
absence  of  a  history  of  diphtheria  aids  in  establishing  the  diagnosis. 

In  275  cases  reported  by  !Myers,  80  died,  or  29  per  cent. 

Course. — A  mild  case  of  diphtheria  will  show  exfoliation  of  tlie  exudate 
on  the  tons'ls  and  pharynx  about  twenty-four  to  forty-eight  liours  at'lcr  a 
sufTicient  dose  of  antitoxin  has  been  injected.  In  four  or  five  days  after  the 
beginning  of  illness,  the  disease  usually  disapj)ears,  so  tliat  there  is  no 
visible  evidence  of  the  sninc. 

In  a  severe  case'  (male,  8  years  old)  seen  by  me  in  October,  in04,  in  the  wards 
of  the  Willard   Parker  Hospital,  tlie   exudate  completely  covered  the  fauces.      Tlie 


^  The  coloied  illustration  D.  Plate  X\',  was  drawn  from  this  case  at    tlie  bed- 
side in  the  Willard  Parker  Hospital. 


564  THE  INFECTIOUS  DISEASES. 

tonsils,  uvula,  and  pharj-nx  were  covered  with  one  large  mass  of  pseudo-membranes. 
The  cervical  glands  were  very  much  enlarged.  The  case  looked  decidedly  septic. 
An  injection  of  5000  units  of  antitoxin  was  given  on  the  first  day,  soon  after  ad- 
mission to  the  hospital.  A  second  injection  of  5000  units  was  given  on  the  second 
day.  A  third  injection  of  5000  luiits  was  given  on  the  third  day.  A  fourth 
injection  of  5000  units  was  given  on  the  fourth  day,  so  that  20,000  units  were  admin- 
istered during  the  first  four  days  after  admission  to  the  hospital.  The  membrane 
exfoliated,  the  swelling  of  the  glands  disappeared  and  one  week  after  his  admission, 
the  throat  was  clear  and  he  was  eonvalescent.- 

A  mild  case  of  diphtheria  may  last  from  five  to  eight  days.  Severe 
types  may  last  many  weeks.  No  case  of  diphtheria  should  be  considered 
to  have  run  its  course  until  the  heart's  action  is  normal  and  the  general 
condition  good.  Sudden  death  may  come  from  over-exciting  a  weakened 
or  damaged  heart  if  proper  caution  is  not  used. 

Prognosis. — The  uncertainty  of  this  disease  and  the  ease  with  which 
complications  follow  must  be  taken  into  consideration  in  giving  the  prog- 
nosis in  a  given  case  of  diphtheria.  A  child  suffering  from  diphtheria, 
wlio  was  brought  up  in  unsanitary  surroundings  or  one  deprived  of  breast- 
milk,  will  suffer  much  more  than  one  favored  with  the  opposite  conditions. 
Such  factors  are  important  in  giving  an  opinion.  A  child  with  rickets  is 
more  liable  to  succumb  to  an  infection  from  diphtheria  and  may  possibly 
die,  when  a  child  with  a  strong  normal  body  and  healthy  internal  organs 
will  recover.  In  this  disease  we  therefore  note  that  it  is  the  "survival  of 
the  fittest."  When  diphtheria  follows  typhoid,  or  when  it  is  a  complica- 
tion of  a  severe  systemic  infection,  like  scarlet  fever,  then  great  care  should 
be  exercised  in  venturing  an  opinion  as  to  the  probable  outcome  of  the 
attack. 

The  guide  in  estimating  the  prognosis  of  any  case  of  diphtheria  should 
always  be  the  condition  of  the  heart.  A  very  rapid  pulse  or  a  gradually 
increasing  pulse-rate  are  bad  signs.  The  temperature  cannot  be  looked 
u])on  as  the  most  impotant  factor  in  determining  the  outcome  of  this  con- 
(]ition.  I  have  seen  cases  of  diphtheria  in  hospital  as  well  as  in  private 
practice  where  normal  temperatures  prevailed  and  still  septic  conditions 
were  positive.  Such  cases,  showing  a  low  inflammatory  type  having  slight 
elevations  of  temperature,  rarely  recover.  The  prognosis  is  also  influenced 
by  the  time  at  which  the  treatment  was  commenced.  When  antitoxin  is 
injected  on  the  first  or  second  day  of  the  disease  the  outcome  is  brighter 
naturally  than  when  the  disease  extends  without  specific  treatment.  The 
mortality  is  greatest  in  children  under  '3  years  of  age. 

Prophylaxis. — Tn  no  disease  should  we  be  more  careful  than  in  diph- 
theria. Strict  isolation  of  all  cases  should  be  enforced,  so  that  no  trans- 
mission of  the  disease  can  take  place.     Disinfection  of  infected  clothing, 


''This  case  was  reported  by  me  at  a  meeting  of  the  New  York  State  Medical 
Association  held  October  19,  1904. 


DIPHTHERIA.  565 

bedding,  etc.,  should  be  strictly  carried  out.  Read  article  on  "Disinfection," 
page  93-1. 

Visitors  should  never  be  permitted  in  a  room  where  diphtheria  exists. 

The  vital  point  to  be  considered  is  how  to  prevent  complications.  The 
(juestion  arises :  can  complications  be  prevented  by  proper  treatment  ?  We 
certainly  can  if  treatment  is  commenced  early  in  the  disease.  We  must 
carefully  watch  all  the  functions  of  the  body  and  stimulate  those  that  do 
not  seem  to  act.  The  emunctories  are  the  most  important  which  require 
watching.  If  the  kidneys  are  found  secreting  very  small  quantities  of  urine, 
then  we  can  be  reasonably  sure  that  the  toxins  stored  in  the  kidneys  will 
cause  serious  damage.  When  therefore  a  scanty  secretion  of  urine  is  met 
with  it  will  at  once  call  for  active  diuretic  treatment.  The  rule  I  have 
always  followed  is  to  stimulate  icith  mild  diuretic  treatment  from  the  be- 
ginning, and  secure  a  copious  secretion  of  urine.  The  same  is  true  regard- 
ing the  condition  of  the  bowels.  In  no  disease  is  it  as  important  to  have 
food  assimilated  and  to  have  proper  evacuation  as  in  the  course  of  the 
treatment  of  diphtheria. 

We  eliminate  large  quantities  of  toxins  by  the  bowel,  the  skin,  and 
the  kidneys,  hence  we  have  it  in  our  means  to  hasten  recovery  and  at  the 
same  time  we  guard  against  storing  up  poison  in  the  blood. 

The  clothing  should  be  warm.  The  child  should  not  be  exposed  while 
bathing.  We  must  guard  against  draughts,  as  we  know  there 
is  a  peculiar  predilection  for  pneumonia  in  the  course  of  diphtheria.  The 
urine  must  frequently  be  examined.  The  examination  must  not  only  be 
chemical,  but  microscopical.  The  moment  we  find  our  case  complicated 
by  nephritis,  the  same  should  be  given  proper  attention. 

Isolation. — Very  frequently  children  have  Klebs-Loeffler  bacilli  in  the 
throat — so-called  culture  cases — in  the  pre-membranous  stage  of  the  dis- 
ease. Some  of  these  develop  diphtheria  of  the  most  virulent  type.  A  safe 
rule  therefore  is  to  insist  on  the  isolation  of  every  child  having  the  Klehs- 
Loeffler  bacillus  in  the  secretions  of  the  nose  and  throat,  for  weeks  and 
months  if  necessar}',  until  a  swab  from  the  throat  shows  an  absence  of  the 
Klebs-Loeffler  bacillus,  to  guard  against  possible  development  of  fatal  diph- 
theria. 

The  finding  of  diphtheria  bacilli  in  the  throat  without  marked  clinical 
indications  of  diphtheria,  has  no  significance,  according  to  Behring.^ 

He  asserts  that  about  10  per  cent,  of  the  entire  population  carry  diph- 
theria bacilli  in  their  throats  without  resulting  infection.  The  bacilli  have 
lost  their  virulence,  or  else  the  individual  possesses  a  natural  immunity. 
He  considers  all  bacteria  with  the  morphological  characteristics  of  Loeffler's 
bacillus,  true  diphtheria  bacilli,  but  he  would  differentiate  a  simple  angina. 


^  Theiapie  der  Gegenwart  (Berlin). 


566  THE   INFECTIOUS  DISEASES. 

rliinitis,  or  conjunctivit.'s  from  diphtheria,  even  with  diphtheria  bacilli 
numLTous  in  the  organ  involved,  if  there  Avere  no  general  symptoms  of 
diphtheria.  He  affirms  that  it  is  useless  and  nonsensical  to  isolate  persons 
who  have  been  exposed  to  diphtheria.  It  is  impossible  to  free  people  from 
the  bacilli  f)r  to  keep  them  permanently  free.  Infection  results  from  a  pre- 
disposition, which  is  in  turn  due  to  a  lack  of  antitoxic  serum  in  the  blood. 
The  antibodies  which  undoubtedly  exist  in  the  blood  of  numerous  indi- 
viduals are  prol)ably  produced  ])y  the  vital  activity  of  avirulent  diphtheria 
bacilli  in  their  throats.  He  consequently  suggests  that  it  might  be  possible 
to  induce  auto-immunization  by  transplanting  avirulent  diplitheria  bacilli 
into  the  throats  of  other  human  beings.  The  comparative  immunity  of 
physicians  to  diphtheria  may  be  due  to  the  repeated,  unconsc'ous  inocula- 
tion with  small  doses  of  the  virus.  Extensive,  systematic  preventive  inocu- 
lation with  antitoxin  would  induce  a  natural  immunity  to  the  disease  and 
entail  the  final  disappearance  of  diphtheria. 

While  the  view  maintained  by  Behring  is  interesting,  it  certainly  docts 
not  conform  to  modern  clinical  experience.  No  child  should  be  permitted 
at  large  with  diphtheria  baciki,  owing  to  the  possible  fatal  result  entailed 
thereby. 

Immunization  in  DipJitheria. — Immunity  in  the  Nursling:  There 
seems  to  be  an  immunity  conferred  upon  the  nursling.  This  may  be  due 
to  the  anti-toxic  properties  of  serum  contained  in  the  mother's  milk. 

Diphtheria  rarely  attacks  nurslings,  but  most  frequently  attacks  infants 
brought  up  by  hand-feeding — the  bottle  babies.  It  is  most  frequently  met 
with  between  the  second  and  eighth  years.  The  disease  may  recur  and  has 
been  known  to  attack  patients  three  or  four  and  even  more  times. 

How  to  Immunize. — When  a  ease  of  diphtheria  occurs  in  a  family  in 
which  there  are  apparently  very  healthy  children,  then  immunity  can  l)e 
conferred  upon  them  by  giving  an  injection  of  antitoxin.  This  immunity 
is  in  the  nature  of  prophylactic  treatment.  The  average  dose  required  for 
a  child  from  1  to  5  years  is  300  to  400  units.  For  older  children,  from  5 
to  12  years,  between  400  and  500  antitoxin  units  may  be  injected.  No 
further  treatment  will  be  necessary  after  the  injection.  All  aseptic  pre- 
cautions which  are  described  in  the  chapter  on  the  'Tnjection  of  Anti- 
toxin" must  be  used  whether  we  inject  a  large  or  a  small  dose  of  anti- 
toxin. It  must  not  be  supposed  that  because  an  immunizing  dose  of  anti- 
toxin has  been  injected,  that  such  a  child  may  then  l)e  exposed  to  this  dis- 
ease with  impunity.  Experience  has  shown  that  when  children  have  been 
given  an  immunizing  dose  of  antitoxin  and  are  immediately  isolated,  as  a 
rule  they  do  not  take  the  disease.  On  the  other  hand,  if  children  are  per- 
mitted to  remain  in  the  same  mom  with  n  case  of  malignant  diphtheria,  it 
is  quite  plausible  to  assume  that  tliey  will  take  the  disease,  even  though  an 


DIPHTHERIA.  567 

immunizing  dose  of  serum  has  been  injected.  Immunity  is  usually  con- 
ferred for  a  period  of  two  or  three  weeks.  It  is  a  good  plan  to  repeat  this 
same  immunizing  dose  of  antitoxin  if  diphtheria  still  prevails  in  the  house- 
hold three  weeks  after  the  first  injection  has  been  given.  Children  receiv- 
ing an  immunizing  dose  should  be  treated  as  though  they  were  perfectly 
well  children.  There  should  be  no  restriction  to  their  diet  and  they  should 
be  permitted  to  romp  and  play  in  the  open  air,  and  receive  their  bath  just 
as  though  no  injection  had  been  given. 

The  Xew  York  Board  of  Plealth  reported  a  series  of  immunizing  in- 
jections in  G80G  individuals,  given  b}-  their  inspectors  from  January  1, 
1895,  to  January  1,  1900.  Out  of  the  above  number,  18  contracted  diph- 
theria of  a  mild  type;  1  contracted  diphtheria  complicated  with  scarlet 
fever;  total,  19  cases;  the  last  case  of  scariet  fever  ending  fatally.  The 
Xew  York  Board  of  Health  Division  of  Bacteriology,  from  January,  1898, 
to  January,  1900,  reports  G82  cases  of  diphtheria  which  were  secondary  to  an 
original  case  in  the  same  family.  Under  secondary  are  included  only  those 
cases  which  occurred  at  least  twenty-four  hours  after  and  within  thirty 
days  of  the  primary  case.  Of  these  682  cases,  Gl  died,  a  mortality  of  8.9 
per  cent.  Had  these  G82  cases  received  antitoxin  (immunizing  dose)  when 
the  physician  first  visited  the  families,  probably  not  one  of  them  would 
have  contracted  the  disease.  When  immunity  is  conferred  by  an  injection 
of  antitoxin  it  lasts  about  twenty  days,  provided  it  is  given  twenty-four 
hours  previous  to  actual  exposure. 

As  a  rule  no  harm  will  result  by  the  injection  provided  the  serum  used 
is  of  a  standard  quality.  We  must  not  expect  to  prevent  follicular  tonsil- 
litis or  any  other  disease  by  an  immunizing  injection  of  antitoxin. 

Morrill  reports  that  of  1808  children  immunized  at  least  every  twenty- 
eight  da3's  with  150  to  500  units  of  serum,  7  had  diphtheria;  3  from  in- 
sufficient dosing,  2  within  twent3^-four  hours  of  the  injection,  and  2  in 
twenty-two  and  twenty-three  days.  Of  829  who  had  not  been  given  anti- 
toxin, or  in  whom  more  than  twenty-eight  da3^s  elapsed  after  the  injection, 
9  had  diphtheria,  besides  3  immunized  adults. 

Biggs  and  Gucrard,  from  35  reports  of  17,516  cases  in  which  small 
doses  of  antitoxin  were  given  as  an  immunizing  agent,  state  that  diphtheria 
occurred  in  131  cases;  109  mild  cases  and  1  fatal  case  within  thirty  days 
of  the  date  of  injection;   20  mikl  cases  and  1  fatal  case  after  thirty  days. 

At  the  Xew  York  Infant  Asylum  107  cases  of  diphtheria  occurred 
between  September  and  January,  1895  (30  cases  a  month).  In  October 
bacteriologic  examination  showed  diphtheria  bacilli  in  almost  one-half  of 
the  throats. 

January  Kith  22-1  children  were  given  imiiiun'zing  doses  of  antitoxin, 
and  up  to  February  15th  only  1  case  of  dij)litheria  occurred.    A  second  case 


568  THE  INFECTIOUS  DISEASES. 

then  developed,  and  between  February  15th  and  2Tth,  5  cases.  On  the  25th 
245  children  received  antitoxin,  and  no  cases  occurred  for  thirty-one  days. 
To  sum  up :  before  isolation  and  immunization  107  cases  occurred  in  one 
hundred  and  eight  days;  after  the  latter  was  practiced,  5  cases  in  one 
hundred  and  twelve  days. 

The  occurrence  of  diphtheria  during  an  epidemic  of  measles  at  the 
Xew  York  Foundling  Hospital  added  greatly  to  the  mortality  of  the  dis- 
ease. During  an  epidemic  of  measles  at  that  institution  every  child  was 
given  400  units  of  antitoxin.  The  result  was  most  encouraging,  as  is  shown 
by  the  immunity  conferred  by  the  injection. 

In  149  cases  of  measles,  500  units  of  diphtheria  antitoxin  were  given  at 
the  first  appearance  of  measles  symptoms.  No  cases  of  diphtheria  secondary 
to  measles  occurred  in  any  of  those  cases  for  a  period  of  one  month  at  least. 
Since  the  appearance  of  the  later  report  another  epidemic  of  measles  has 
occurred  at  this  institution.  The  children  were  given  500  units  of  anti- 
toxin each,  but  it  was  apparent  in  a  number  of  instances  that  immunity 
from  diphtheria  did  not  last  for  more  than  eighteen  days  to  three  weeks, 
at  which  time  several  cases  of  diphtheria  occurred,  complicating  or  follow- 
ing measles,  and  generally  proved  fatal.  This  relatively  sliorter  period  of 
immiiniiy  from  diphtheria  in  measles  cases  has  been  noted  in  France  and 
Germany,  and  for  this  reason  Slawyk  recommends  that  the  immunizing 
dose  be  repeated  every  two  weeks  in  measles  epidemics. 

W.  P.  Coues  gives  an  account  of  an  epidemic  of  diphtheria  at  St. 
Mary's  Infant  Asylum,  in  Boston,  1898.  Fifty  children  were  given  doses 
of  antitoxin,  from  50  to  500  units,  the  small  dose  in  a  one-day  infant. 
Urticaria  occurred  in  14  as  the  only  bad  result.  From  February  15th  to 
March  22d  there  were  18  cases  of  diphtheria.  After  the  latter  date,  when 
antitoxin  was  begun,  there  occurred  no  cases  for  three  weeks. 

Krauss  gives  an  extensive  analysis  of  results  of  immunizing  doses  in  122 
hospital  cases,  which  were  divided  as  follows :  44  were  scarlet  fever  cases, 
2  of  which  later  contracted  diphtheria;  31  cases  of  children  were  sent  to 
the  diphtheria  pavilion  and  found  not  to  have  true  diphtheria;  no  cases 
contracted  it;  47  measles  cases,  many  of  them  complicated;  1  developed 
diphtheria. 

Thus,  of  122  cases,  all  of  whom  were  more  or  less  exposed  to  the  dis- 
ease, and  all  ill  with  diseases  most  likely  to  be  complicated  by  diphtheria, 
only  3  became  infected,  on  the  twenty-sixth,  twenty-seventh,  and  forty-first 
day  after  inoculation.  The  dose  of  antitoxin  ranged  from  200  to  400 
units,  the  latter  being  given  to  the  children  with  suspected  diphtheria. 

In  addition  to  the  results  of  immunization  at  the  New  York  Infant 
Asylum,  the  following  report  of  Biggs  will  show  the  result  at  other  insti- 
tutions : — 


DIPHTHERIA. 


569 


Table  Xo.  77. 


Place  of 
Observation 


Children 
Irumun.zeJ. 


Nursery  and 

Child's 

Hospital 


New  York 

Juvenile 

Asylum 


I  Cases  of  Diph 
\  theria  Develop- 
j      ing  among 
I  those  luini   n- 
ized  be  ween 
1  and  30  days. 


Cases  Develop-  Cases  Develo-'- 
ing  within  j  ing  after  30 
24H0UIS  Days. 


0 

0 

0 

0 

Number  of  Cases  of 
Diphthe  ia  that 
Occurred  in  the  Insti- 
tutions Pr.  vious  to 
Immunization. 


46  cases  in  90  days ; 
15  cases  in  18  days 


12  cases  ;  3  cases  in 
2  days 


New  York 

Catholic 

Protectory 

114 

0 

1 

0 

5  cases  in  3  days 

Bellevue 
Hospital 

11 

1  mild  on 
the  19th  day 

3 

one  30th 
one  31st 
one  55th 

2  cases  in  10  days. 
One  or  more  cases 
in    more   than    90 
families 

Total.   .    . 

342 

Modern  Tiseatmext  of  Diphtheria. 

The  treatment  of  diphtheria  requires  careful  consideration  in  each  and 
every  case.  Certain  conditions  must  be  met;  therefore  it  is  wise  to  look 
ahead.     The  treatment  is  divided  into: — 

1.  Hygienic. 

2.  Prophylactic  and  specific. 

3.  ^ledicinal. 

4.  Dietetic. 

Hygienic  Treatment. — Put  the  cliild  to  bed  in  a  large  airy  room. 
The  room  must  be  free  from  draught  and  so  arranged  that  proper  ventiht- 
tion  can  easily  be  carried  out.  Fresh  air  in  the  treatment  of  this  disease  is 
of  prime  importance.  Pseudo-membranous  deposits  in  the  nose,  pharynx, 
laryn.x,  or  tonsils  will  frequently  cause  a  mechanical  impediment  to  the 
entrance  of  oxygen.  Carbonic  acid  poisoning  can  easily  take  place,  and 
the  entrance  of  fresh  air  into  the  lungs  is  of  the  greatest  importance.  In 
simple  diphtheria,  or  if  we  have  an  extension  of  the  croupous  deposits  into 
the  bronchi,  perfect  oxygenation  of  the  lungs  is  demanded.  Having' given 
attention  to  proper  ventilation  we  must  seek  to  maintain  an  equal  tempera- 
ture in  the  room.  The  temperature  of  the  sick  room  should  be  between  65° 
and  72°  F.     The  entrance  of  sunlight  is  of  prime  importance.     When  we 


570  TPIE  INFECTIOUS  DISEASES. 

consider  the  great  antiseptic  properties  of  sunshine  and  its  beneficial  eflfect 
upon  the  patient,  then  we  must  see  the  importance  of  admitting  as  much 
light  and  sunshine  as  possible. 

The  Bath. — Next  in  importance  to  fresh  air  and  sunlight  is  the  bath. 
Every  patient  with  diphtheria  should  be  sponged  twice  daily  with  a  tepid 
sponge  bath.  The  body  should  be  briskly  rubbed  for  a  few  minutes  after 
the  bath  to  stimulate  the  cutaneous  circulation.  By  opening  the  pores  of 
the  skin  we  naturally  favor  elimination,  hence  it  is  advisable  to  encourage 
diaphoresis  by  attend  ng  to  the  skin. 

Specific  or  Antitoxin  Treatment. 

Manner  of  Administering  tlie  Antitoxin. — The  greatest  amount  of 
care  should  be  exercised  in  administering  antitoxin.     The  skin  of  the  pa- 


Fig.   174.— Glass  Aseptic  Antitoxin  Syringe. 

tient,  Ihe  physician's  liands  and  the  needle  used  should  bo  rendered  aseptic. 
It  is  a  good  plan  to  disinfect  the  syringe  with  alcohol  before  filling  the 
same  with  the  antitoxin.  Abscesses  need  not  form  at  the  base  of  puncture 
if  care  and  attention  are  bestowed  to  strict  cleanliness. 

Part  of  the  Body  Chosen. — Wherever  a  loose  fold  of  skin  can  be 
pinched  up,  for  example  on  the  thigh,  the  loose  tissues  of  the  abdomen,  tlie 
outer  portion  of  the  chest,  or  between  the  shoulder  blades,  the  needle 
should  be  inserted  into  the  cellular  tissue  and  the  antitoxin  gradually  in- 
jected. The  puncture  should  then  be  sealed  with  a  drop  of  collodion.  Fill 
the  syringe  with  antitoxin,  and  expel  all  air  before  injecting  the  patient. 
Sudden  death  after  the  injection  of  antitoxin  has  been  reported  when  this 
precaution  was  neglected;    and  air  was  injected  into  a  vein. 

A  convenient  method  of  injecting  antitoxin  is  with  the  syringe  adopted 
by  Messrs.  Mulford  and  Wampole.  Tlic  glass  barrel  containing  the  anti- 
toxin has  an  aseptic  piston-rod  and  needle  attached.  This  docs  away  with 
an  extra  syringe  as  each  dose  of  antitoxin  is  contained  in  one  of  these 
aseptic  holders. 


DIPHTHERIA.  571 

The  Administration  of  Antitoxin  Per  Orem. — Some  writers  have  ad- 
vocated giving  antitoxin  by  the  mouth.  The  writer  has  administered  anti- 
toxin in  drachm  doses  until  a  sufficient  quantity  of  antitoxin  was  given. 
One  thousand  units  were  given  in  this  manner,  in  a  very  mikl  form  of 
diphtheria.  The  disease  spread  in  spite  of  this  administration  and  there  was 
no  apparent  benefit  from  its  use.  When,  however,  3000  units  were  given 
subcutaneously,  the  disease  not  only  improved,  but  the  child  recovered. 

Administration  of  Antitoxin  Per  Rectum. — Several  years  ago  the 
writer  was  induced  to  use  antitoxin  in  various  ways.  He  therefore  injected 
2000  units  into  the  colon.  The  part  was  first  thoroughly  flushed  with  soap 
and  water  to  remove  fsccs,  and  after  it  was  completely  drained,  the 
required  dose  of  antitoxin  was  injected  through  a  long  rubber  catheter. 
Most  of  the  antitoxin  remained  and  was  absorbed. 

Several  cases  of  this  kind  were  reported  at  a  meeting  of  the  New  York 
County  Medical  Association,  in  1897,  by  the  writer.  As  it  was  impossible 
to  control  the  sphincter  in  some  cases  a  large  portion  of  the  antitoxin  was 
lost.  It  was  impossible,  therefore,  to  state  just  how  much  of  this  healing 
serum  remained  and  was  absorbed.  In  several  cases  in  which  this  was  used 
an  apparent  benefit  was  manifested ;  on  the  other  hand  in  a  very  malig- 
nant case  in  which  the  sphincter  ani  was  relaxed,  the  antitoxin  was  not 
retained  and  flowed  from  the  colon  and  rectum  and  was  lost.  I  therefore 
cannot  advocate  the  injection  of  antitoxin  excepting  by  the  subcutaneous 
method. 

It  is  well  at  the  onset  of  a  case  of  diphtheria,  be  it  confined  to  the 
tonsils,  to  a  large  or  small  area,  to  treat  the  disease  as  though  it  were 
much  worse  than  it  appears.  Locally  we  see  the  macroscopic  evidence 
by  the  presence  of  the  pseudo-membrane.  We  cannot  see  nor  can  we  know 
liovv  much  toxin  has  been  thrown  out  by  the  Klebs-Loeffier  bacillus,  as  the 
same  enters  the  general  circulation.  Tl^hat  is  recognized  as  a  toxic  con- 
dition is  no  more  or  less  than  a  given  amount  of  poison  thrown  into  the 
system  by  these  poisonous  bacilli.  Acting  upon  our  knowledge  of  the  bac- 
teriology and  pathology  of  this  disease  we  can  lay  down  certain  rules  for 
tlie  guidance  of  any  one  in  the  treatment  of  diphtheria.  First  and  fore- 
most it  is  necessary  to  give  a  sufficient  quantity  of  antitoxin  to  neutralize 
any  and  all  poison  tliat  may  be  in  the  system. 

The  specific  action  of  antitoxin  is  well  known  and  universally  recog- 
nized. 

Dose  Required. — Mild  Cases:  The  dose  depends  on  tlie  severity  of  the 
infection.  '^I'lio  usual  amount  required  for  a  child  from  1  to  5  years  old 
with  a  mild  form  of  diphtlioria  is  1500  to  3000  units.  If  there  is  no  elTect 
noticeable  witliin  twelve  to  twenty-four  hours,  tlien  a  second  injection  of 
flic  same  quantity  sliould  l)e  given.  A  child  5  to  10  years  of  age  sliould 
be  given  at  least  3000  to  5000  units  at  its  first  injection,  to  be  followed  in 


572 


THE   INFECTIOUS  DISEASES. 


twelve  to  twenty -four  hours  by  another  injection  of  the  same  amount  if 

there  is  no  amelioration  of  the  symptoms. 

Severe  Cases. — \Yhen  we  are  dealing  with  a  severe  toxaemia  with  marked 

general  depression  and  large  masses  of  pseudo-membranes  in  the  throat, 

then  at  least  10,000  units  of  antitoxin^  should  be  injected  in  the  beginning. 

Wlien  the  cervical  lymph  glands  are  enlarged  and  there  is  slight  or  severe 

evidence  of  stenosis,  then  at  least 
10,000  units  should  be  injected  in 
the  beginning. 

Indications  for  a  Second  and 
Third  Injection  of  Antitoxin. — If 
twelve  hours  after  the  first  injec- 
tion there  is  no  visible  effect  on  the 
pseudo-membranes,  if  the  child  is 
not  brighter,  if  the  appetite  is  poor, 
and  if  the  heart's  action  is  very 
poor,  in  other  words,  if  there  is  no 
visible  improvement,  then  by  all 
means  inject  a  second  dose  of  anti- 
toxin. 

The  necessity  for  the  third  in- 
jection depends  upon  the  pulse, 
temiDerature,  the  condition  of  the 
glands  of  the  neck,  and  upon  the 
macroscopic  condition  of  the 
throat.  If  no  improvement  exists, 
then  the  third  injection  is  impera- 
tive. 

Laryngeal  Stenosis. — It  is  al- 
ways a  safe  plan  to  give  an  injec- 
Fig.  175.-Temi)erature  Chart  from  a  Case  ^-ioj^    of    5000    units;    and    if    the 

stenosis  does  not  disappear  in 
twelve  hours,  I  give  an  additional 
injection  of  5000  units,  so  that  in 

all  10,000  units  may  be  injected  during  the  first  twenty-four  hours;  (read 

chapter  on  "Intubation"). 

The  above  treatment  with  antitoxin  will  be  serviceable  when  we  are 

dealing  with  a  pure  Klebs-Locfflcr  infection,  but  there  are  a  great  many 


\ 


190A- 

DATES  OF  OBSERVATIONS    | 

^«^ 

15 

16 

17 

18 

19 

am:pm 

Cent. 

Fahr. 

ANI>M 

ani:pm 

AM 

PM 

am:pm 

39°  ~ 

33'~ 

-103°- 

; 

I 

-102°". 

'\ 

] 

-101° -i 

;\ 

: 

'lOO°-i 

1 

37~ 

-99° •< 

#^1 

:     ; 

J 

^ 

86° 

-98° -5 

v/ 

-97°- 

i  ioot 

likU 

IT. 

r  iiL/'t 

cM 

-96°- 

i/y» 

per  minute 

JO  «3 

1>^ 

b 

s 

Respiratione 
per  minute 

^ 

^ 

of  Diphtheria,  showing  the  Specific  Effect  of 
Antitoxin  on  the  Temperature.  Note  also 
the  effect  on  the  pulse.     (Original.) 


'  It  is  frequently  necessary  to  repeat  the  dose  so  that  10,000  units  may  be 
given  (luring  the  first  day  of  illness  if  no  improvement  is  noted.  The  dose  of  10,000 
units  may  be  repeated  during  the  first  three  days  if  no  improvement  is  noted.  T  am 
in  favor  of  large  doses  and  watch  the  child's  condition  as  the  guide  when  sufficient 
antitoxin  has  been  injected. 


DIPHTHERIA. 


573 


cases  in  Avhich  we  have  a  mixed  infection,  and  the  streptococcus  infection 
predominates. 

There  are  contributing  factors  frequently  leading  to  a  fatal  termination. 
First  and  foremost  is  the  presence  of  the  streptococcus  in  addition  to  the 
Klehs-Loeffler  infection.  In  these  mixed  infections  we  have  in  addition  to 
tlie  general  diphtheria,  a  distinct  streptococcemia.  In  these  cases  antitoxin 
is  inert  as  regards  the  streptococcus.  We  frequently  have  hroncho-pneu- 
monia,  nephritis,  arthritis,  otitis,  and  local  al^scesses  due  to  the  invasion  of 
tlie  streptococcus.  To  neutralize  sucli  mixed  infections  we  require  besides 
tlie  Klebs-Loeffler  antitoxin  a  streptococcus  antitoxin  or  a  potent  antistrep- 
tococcus  serum. 

llie  hactrriological  findings  will  therefore  he  the  guide  in  tlie  future  in 
detennining  first,  vhelher  a  culture  from  tlie  tliroat  shoics  a  mixed  or  on 
unmixed  infection  and  in  addition  to  this  bacteriological  examination,  tlie 
blood  must  he  examined  to  determine  the  presence  or  absence  of  a  strepto- 
coccemia. The  treatment  must  be  based  on  scientific  data,  hence,  it  should 
conform  with  the  result  of  what  is  found  by  culture  from  the  throat  and  by 
the  thorough   examinaiion  of  the  blood. 

If  we  can  inject  a  sufficient  quantity  of  antitoxin  to  stimulate  cell 
activity  and  neutralize  general  toxamiia/  then  we  give  our  patient  the  great- 
est opportunity  to  eliminate  this  deadly  poison  and  to  Ijegin  convalescence. 

The  ordinary  sJiortcomings  that  are  most  frequently  met  with  consist 
of  phicing  too  much  reliance  on  the  specific  na.ture  of  antitoxin  regardless 
of  other  vital  necessiiies.  In  this  infectious  disease,  where  there  is  marl-ed 
h'ucocytosis  and  otlier  evidences  of  subnormcd  hannic  conditions,  the  indi- 
cation next  to  antitoxin  is  for  restorative  treatment,  especially  nairiiion. 

Dry  Antitoxin. — Dry  antitoxin  is  a  golden-yellow  crystalline  substance 
(juite  soluble  in  sterilized  water. 

Directions  for  r.^r.— The  remedy  iiiust  l)e  dissolved  immediately  before 
use  by  adding  from  1  to  4  cubic  centimeters  cold  sterilized  water  by  means 
of  a  sterilized  pipette  into  a  bottle  of  antitoxin.  The  solid  serum  dissolves 
slowly;  the  greatest  caution  must  be  used  not  to  contamiiuite  the  solid 
serum,  as  it  contains  no  antiseptic.  Small  vials  containing  lOOO  units  con- 
stitute a  healing  dose. 

It  is  then  injected  info  the  connective  tissue  of  the  inlrascapular  re- 
gion, buttocks,  thighs,  or  in  the  loost^  connective  tissue  of  the  abdomen  or 
(■best.  A  series  of  clinical  results  in  severe  and  mild  diphtheria  A\as  I'e- 
])orted  by  me  at  the  Section  on  Pediatrics  of  tlie  American  ^ledical  .\sso- 
ciation,  1899.     Very  good  itsuKs  were  noted. 

The  following  case  of  diphtheria,  complicated  by  laryngeal  stenosis, 
will  illustrate  the  Tuode  of  administration  and  its  result : — 


1  In  septic  iliplitlipria  whore  profound  toxneniia  exists  ini   intravenous   initcliuu 
of  10,000  to  20,000  units  of  antitoxin  should  he  used. 


574 


THE  INFECTIOUS  DISEASES. 


Lizzie  G.,  born  U.  S. 

Family  History. — Negative;    sister  had  diphtheria  last  year. 

Habits  and  Surroundings. — Attends  public  school;  tenement,  two  rooms;  two 
adults,  four  children.  Cleanliness  leaves  a  great  deal  to  be  desired.  Ventilation 
bad. 

Prcrioiis  History. — No  contagioiis  diseases.  Inclined  to  tonsillar  inflannna- 
tions.     Adenoids. 

Present  History. — ^The  source  of  infection  is  probably  to  be  sought  in  school 
or  Sunday  school.  Lymphatic  diathesis.  The  disease  began  on  April  21st,  when  the 
child  seemed  feverish,  restless,  and  complained  of  sore  throat.  A  physician*  who 
was  consulted,  declared  that  the  child  was  suffering  from  "catarrh."  The  mother 
says  she  noticed  some  white  spots  in  the  child's  throat.  There  was  anorexia,  cougli 
and  difficulty  in  swallowing.  During  tlie  following  night  the  cough  assume  1  a 
eroupj^,  brassy  character,  and  in  the  morning  the  mother 
found  that  the  child  was  breathing  rapidly  and  noisily,  an  1 
that  the  fever,  sore  throat,  headache  and  nausea  were  inten- 
sified. There  was  considerable  prostration.  In  the  after- 
noon I  saw  the  case,  with  Dr.  Geo.  A.  Saxe.  The  child  pre- 
sented a  considerable  degi'ee  of  laryngeal  stenosis,  so  that 
we  informed  the  mother  that  intubation  would  be  nec- 
essary. 

Examination. — An  anaemic  child,  fairly  well  nouris'.ied, 
but  with  feeble  musculature.  The  skin  pale,  hot  and  dry. 
There  was  no  eruption.  Herpes  labialis.  The  bowels  were 
regular;  no  vomiting.  The  temperature  was  101°  F.,  the 
pulse  108;  the  respiration  48,  shallow  and  noisy.  The 
intercostal  spaces  and  the  suprasternal  notch  and  .sterno- 
costal angle  are  depressed  at  each  inspiration.  There  is  a 
croup}'  cough.  The  tongue  is  coated  and  moist.  There  is 
a  slight  nasal  discharge.  The  conjunctivae  are  normal. 
There  are  enlarged  glands  on  both  sides  of  the  neck,  which 
are  hard,  mobile,  and  not  painful  to  the  touch.  The  tonsils, 
arch  of  the  palate,  and  posterior  wall  of  the  pharynx  show 
the  presence  of  yellowish-gray  spots  of  false  membrane. 
They  are  exceedingly  difficult  to  dislodge.  The  surround- 
ing mucosa  is  diffusely  inflamed.  A  culture  on  sei-um  agar 
was  planted  with  some  of  the  exudation,  and  within  twenty- 
four  hours  sufficient  growth  appeared  on  the  surface.  The 
bacteriologist  reported  the  presence  of  true  Klebs-Loeffler 
bacilli.      (Report  New  York  Health  Board,  No.  2813.) 

There  was  no  pain  in  the  chest,  there  was  distinct 
bronchial  fremitus  on  palpation.  Auscultation  was  ex- 
tremely difficult,  on  account  of  the  laryngeal  stenosis,  and 
revealed  sibilant  and  sonorous  breathing,  subcrepitant  Titles 
and  pulmonary  vocal  resonance.  Percussion  soimds  normal. 
Fi".  17G. — Tempera-  The  heart  action  regular,  no  murmur.  The  abdomen  nega- 
ture  Chart  from  a  live.  The  faces  are  of  normal  color  and  consistency.  Ths 
Case  of  Diphtheria.  urino  specific  gravity  1022,  no  albumin,  no  casts,  quantity 
Sho-sving  Effect  of  Dry  average,  road  ion  acid,  colf)r  normal. 
Antitoxin.    (Original.)  Diagnosis. Tonsillar  and  laryngeal  diphtheria. 


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DIPHTHERIA.  575 

Progn'isis. — Grave,  on  account  of  the  amount  of  laryngeal  stenosis. 

Treatment. — On  the  same  day,  an  hour  after  the  first  visit,  Dr.  Saxe  injected 
1500  units  of  the  dry  antitoxin  of  Behring  into  the  right  hypochondriac  region. 
Temperature  at  injection  102.4°  F. ;  pulse  120;  respiration  48.  Calomel  tablets, 
0.015  t.  i.  d.  Inimctions  of  25  per  cent,  mercurial  ointment  tO'  the  neck.  Semi-solid 
foods  were  ordered.  At  8.30  p.m.  on  the  siune  day  I  found  the  child  suffering  with 
severe  laryngeal  stenosis  and  ininieiUateh/  intubated.    The  relief  was  instantaneous. 

April  23d.  On  the  following  morning  the  child's  respiration  was  perfectly 
normal,  being  at  the  rate  of  24  per  minute.  The  temperature  was  101.2°  F.,  the 
pulse  90,  and  the  general  condition  considerably  improved.  There  was  still  con- 
siderable cough  and  stringy  mucus  was  expectorated.  The  child  was  given  a  mix- 
ture containing  2  grains  of  ammonium  carbonate,  one  drop  of  the  tincture  of 
strophanthus,  20  minims  of  syrup  of  wild  cherry  in  a  teaspoonful  of  water.  The 
bowels  were  regular.  The  other  medication  was  continued  in  the  same  way.  No 
more  antito.xin  was  given. 

April  24th.  The  child's  breathing  is  normal,  and  there  is  no  sound  of  an  ob- 
struction, as  there  often  is  in  intubated  cases.  The  membranes  disappeared  from 
pharynx,  tonsils,  and  palate.  The  examination  of  the  heart  and  chest  is  negative. 
The  herpes  labialis  and  the  swollen  cervical  glands  are  beginning  to  disappear.  The 
temperature  is  100.0°  F.,  the  pulse  84,  and  the  respiration  24.  The  child  sleeps  \\e.\ 
at  night  and  has  more  appetite. 

April  25th.  The  general  condition  is  very  good.  The  bacilli  have  disappeared 
from  the  throat,  as  attested  by  bacteriological  examination.  The  temperature  is 
100.2°  F.,  the  respiration  and  pulse  the  same  as  on  the  preceding  day. 

April  2Cth.  The  child's  cough  is  less  frequent  and  the  breathing  is  normal. 
The  appetite  is  very  good,  the  tongue  clean,  and  the  cervical  glands  almost  normal. 
The  same  medication  is  continued.  The  temperature  is  99°  F.,  the  pulse  84,  and  the 
respiration  24. 

April  27th.  The  child  was  extubated  (on  the  fifth  day).  The  tube  was  coated 
with  lime  salts,  but  its  lumen  was  free.  There  was  no  dyspnea,  and  the  child  con- 
tinued to  breathe  easily  after  the  extubation.  The  temperature  was  98.6°  F. ;  the 
general  condition  very  good. 

In  this  case  no  sequekc  were  observed,  though  on  the  day  after  the  intubation 
the  child  developed  symptoms  resembling  those  of  a  broncho-pneumonia. 

Dietetic  Treatment. — As  a  tissue  and  blood  builder  no  medication 
equals  food.  It  is,  tl'.erefore,  imperative  to  support  the  general  nutrition  by 
proper  feeding.  Milk  diluted  with  some  cereal  decoction,  like  oatmeal,  bar- 
ley or  rice,  will  be  l)elter  borne  than  pure  milk  alone.  Buttermilk  or  zoolak 
may  be  given.  Sometimes  it  is  necessary  to  partially  })eptonizc  milk  to 
render  it  more  aljsorbable.  If  the  child  is  old  enough  the  yolk  of  a  raw  egg 
can  be  added  to  the  milk  (egg-nog).  Concentrated  beef  broth,  chicken 
broth,  clam  broth  or  oyster  broth  should  be  tliought  of.  When  feeding,  once 
in  three  liours,  it  is  a  good  plan  to  give  some  of  this  concentrated  broth,  fol- 
lowed in  three  hours  by  a  milk  feeding,  and  so  alternate.  In  this  manner 
we  give  our  patient  milk  once  in  si.\  hours.  Acid  fruits,  such  as  oranges, 
lemons,  grapes,  and  cranberries  are  very  well  borne.  When  acid  fruits  are 
ordered  they  should  be  given  an  hour  before  milk  feeding.  Oldei-  children 
can  be  given  raw  scraped  steak,  calf's-foot  j''lly,  and  ice  cream   wliicli   is 


576  THE  INFECTIOUS  DISEASES. 

nutritious  and  pleasant.  When  it  is  difficult  to  feed  by  mouth  owing  to 
excessive  vomiting  or  to  anorexia,  or  where  intubation  has  been  performed, 
it  is  a  good  plan  to  let  the  stomach  have  absolute  rest  and  to  depend  on : — 
Rectal  Feeding. — No  more  than  two  ounces  should  be  injected  at  one 
time. 

Milk,   predigested    1  ounce 

Starch  water    1  ounce 

Laudanum     1  minim 

To  be  injected  slowly  tlirough  a  colon  tube,  after  both  colon  and  rectum  have 
been  cleauseil  by  a  soap-suds  enema. 

If  the  small  nutritive  enema  is  well  retained  we  can  repeat  the  injection 
once  every  four  hours,  and  add  the  yolk  of  a  raw  egg  to  the  above  formula 
of  milk,  starch  and  opium.  Next  in  importance  to  giving  the  proper  dose 
of  antitoxin  is  the  nutrition  of  the  body  which  has  just  been  considered. 

Elimination  of  Toxins. — The  elimination  of  toxic  elements  can  only 
take  place  by  means  of  the  bowels,  kidneys,  and  skin.  Xormally  in  febrile 
conditions  there  is  a  general  torpidity  of  the  emunctories.  Thus  it  is  ap- 
parent that  a  dose  of  calomel,  citrate  of  magnesia,  or  an  alkaline  solution 
like  the  milk  of  magnesia  or  a  laxative  mineral  water,  wall  aid  in  the  per- 
formance of  these  functions. 

Medicinal  Treatment. — It  is  advisable  to  remove  the  putrid  membranes 
from  the  nose  and  throat  and  also  the  catarrhal  discharges.  To  do  this, 
mechanical  treatment  consisting  of  the  cleansing  of  the  nose  with  a  salt 
solution  of  the  strength  of  one  dram  of  table  salt  to  one  pint  of  water  is 
useful.  A  weak  (I/2  per  cent.)  solution  of  permanganate  of  potash  can  also 
be  used  to  cleanse  the  nose  with  the  aid  of  a  syringe  (see  Fig.. 210). 

Septic  products  in  the  nose  and  throat  will  frequently  lead  to  a  fatal 
termination.  Their  presence  is  a  constant  menace  to  the  blood  by  inviting 
toxaemia.  In  addition  thereto  they  give  rise  to  fever  and  not  infrequently 
septic  material  will  find  its  way  from  the  nose  and  pharynx  into  the 
Eustachian  tubes,  causing  abscesses.  If  neglected  it  may  lead  to  mastoid 
involvement  and  brain  abscesses  or  to  septic  meningitis,  with  little  or  no 
chance  of  recovery. 

By  observing  the  enlarged  lymph  glands,  it  is  surprising  to  see  wliat 
good  result  is  apparent  after  cleansing  the  nose  and  pharynx. 

Local  Treatment  of  the  Pseudo-membranes. — The  solvent  effect  of  local 
remedies  I  have  never  been  able  to  see.  When  papayotin  has  l)een  used,  I 
have  l)een  disappointed  in  its  effect.  Creosote  vapors,  by  adding  a  dram  of 
beechwood  creosote  to  a  pint  of  water  and  allowing  the  air  to  become  im- 
pregnated with  the  vapor  has  shown  some  good  in  a  few  instances.  Lugol's 
solution  of  iodine  (half  strength)  a])|)]i('d  by  means  of  absorbent  cotton,  can 
be  recommended.  A  steam  atomizer  containing  a  weak  solution  of  (2  per 
cent.)  sulphurous  acid  is  sometimes  of  value.     The  latter  has  been  used  by 


DIPHTHERIA  577 

me  and  certainly  can  be  recomniendod  when  there  are  extensive  necrotic 
patches.  It  is  far  better  than  peroxide  of  hydrogen.  Other  local 
treatment  which  1  have  used  with  benefit  is  the  inunction  of  unguentuni 
Crede  into  the  cervical  glands,  rubbed  in  at  least  fifteen  to  twenty  minutes 
two  or  three  times  a  day.  An  ice-bag  w^orn  continually  can  also  be  recom- 
mended when  there  is  an  extensive  oedema. 

Oxygen  is  indicated  and  required  when  there  is  the  slightest  evidence  of 
cyanosis.  It  will  also  relieve  dyspnoea  when  present.  It  is  especially  indi- 
cated during  broncho-pneumonia,  which  so  often  complicates  diphtheria. 

Fever  Treatment. — It  is  a  wise  plan  to  exclude  antipyretic  drugs  during 
the  treatment  of  fever  in  diphtheria.  The  best  antipyretic  measures  con- 
sist in  sponging  with  evaporating  lotions  such  as  alcohol  and  water  or  acetic 
ether,  locally.  Cold  packs  and  flushing  the  bowel  with  cold  water  are  very 
serviceable  in  some  cases.  When  high  fever,  due  to  pneumonia,  to  nephritis 
or  to  any  other  complication  exists,  the  same  should  be  treated  as  though  the 
disease  existed  independent  of  the  diphtheria. 

When  fever  exists  and  the  child  cries  continuously  then  the  ears 
should  be  examined.  Frequently  an  otitis  media  will  keep  up  high  fever 
until  the  drum  is  ruptured.  Ten  to  20-drop  doses  of  sweet  spirits  of  niter 
are  valuable  if  given  several  times  a  day.  During  the  febrile  stage  of 
diphtheria  calomel  in  Vio  to  ^/o-grain  doses,  repeated  several  times  a  day, 
is  a  useful  adjuvant  in  fever  treatment. 

Si'unulation. — Owing  to  the  depressing  effect  of  the  diphtheritic  poisons, 
stimulation  should  Ijegin  early.  Strychnine,  Vioo  grain,  for  a  child  1  year 
old,  repeated  three  or  four  times  a  day,  may  be  given.  The  dose  can  bo 
gradually  and  cautiously  increased  until  a  systemic  effect  is  noticeable. 
Children  will  tolerate  very  large  doses  of  strychnine  just  as  they  will  tolerate 
very  large  doses  of  whiskey.  They  can  be  combined.  Tokay  wine,  cham- 
pagne and  coffee  are  valuable  cardiac  stimulants.  Caffeine  citrate  and 
sparteine  are  also  serviceable  for  enfeebled  heart's  action.  The  prognosis 
of  a  case  of  (li])htheria  is  certainly  better  in  a  case  where  the  heart  has  been 
supported  until  the  toxitMiiia  has  ])assed  away. 

Paralij.sis. — 'i'he  internal  treatment  of  paralysis  consists  of  strychnine 
and  the  usual  restorative  treatment.  Galvanic  and  faradic  electricity  are 
good.    Absolute  rest  in  bed  and  gentle  massage  are  indicated 

Statistics  of  the  Kaiser  and  Kaiserin  Friedrich  Hospital  in  Berlin 
show  a  very  interesting  comparison  l)etween  the  juortality  Ix'fore  and  after 
antitoxin  was  used. 

The  death  rate  was  30.5(5,  35.57,  and  45.78  in  three  successive  years, 
or  an  average  of  39. G3  per  cent.  In  the  year  1S!)4,  when  the  serum  treat- 
ment was  first  used,  although  experimentally,  there  were  two  interesting 
data:  first,  the  mortality  among  cases  treated  with  antitoxin  was  16.6  per 
cent.;    second,  those  treated   without   antitoxin,    mortality   27.8   per  cent. 


578 


THE  INFECTIOUS  DISEASES. 


Ill  the  following  year   (1895)    all  cases  of  diplithoria  were  injected  with 
antitoxin;    the  mortality  fell  to  ll.'.^  per  cent. 

I  lit  in  anil  y. — Four  hundred  and  sixty  children  were  injected  with  tlie 
object  of  ))roducing  ininiimity.  Of  these  only  1(S  canie  down  with  diph- 
theria.    All  of  these  cases  were  mild  and  not  one  died. 


Table  No.  "iS.—DiiJhtheria  Cokcs — Wilhnd  I'aikir  Hospital. 

TREATED   WITHOUT   ANTITOXIN. 


Year. 

No.  Treated. 

Died. 

-Miirtality— Percent. 

J^ecoveries — Per  Cent. 

1889 

391 

79 

20.20 

79.80 

1890 

311 

(17 

21.54 

78.46 

1891 

303 

So 

28.05 

71.95 

1892 

311 

79 

25.40 

74.00 

1893 

3.-)  7 

108 

30.25 

09.75 

1894 

732 

205 

28.01 

71.99 

Totiil. 

2405 

623 

25.57 

74.42 

TREATED    WITH    ANTITOXIN. 


Year. 

No.  Treated. 

Died. 

Mortality — Per  Cent. 

Recoveries  — Per  Cent. 

1895 

825 

190 

23.03 

76  97 

1896 

860 

205 

23  84 

76.16 

1897 

881 

214 

24.29 

75  71 

1898 

612 

109 

17.81 

82.19 

1899 

781 

192 

24.58 

75.42 

1900 

823 

238 

28.92 

71.08 

1901 

919 

275 

29.92 

7:).  08 

1902 

1112 

271 

24.37 

75.63 

1903 

1281 

356 

27.79 

72.21 

1904 

1402 

356 

25.39 

74.61 

*1905 

478 

98 

20.50 

79.50 

Total. 

10574 

2504 

23.67 

70.33 

♦On  account  of  rebuilding  the  Ho.spital,  no  i)atient.s  were  received  after  June  17th. 


INTUBATION. 


579 


A  comparative  study  of  the  deaths  before  antitoxin  was  used  and  the 
present  method  of  treatment,  where  all  cases  receive  antitoxin,  can  hardly 
be  nuide.  I  frequently  see  septic  cases  sent  to  the  hospital  in  a  moribund 
condition.  The  city  hospital  is  used  as  a  dumping  ground  for  all  nuilignant 
cases,  hence,  the  high  mortality  rate.  The  cases  admitted  belong  to  the 
laboring  class  of  people.  As  these  people  are  very  poor,  they  delay  sending 
for  a  physician  until  severe  laryngeal  stenosis  sets  in.  When  the  disease 
has  gained  headway  and  there  is  a  general  septic  condition,  recovery,  as  a 
rule,  is  doubtful. 

Intubation. 

When  laryngeal  stenosis  occurs  during  a  case  of  diphtheria,  then  we 
must  prepare  for  intubation. 

The  following  symptoms  demand  intubation : — 

Labored  breathing. 

A  gradual  and  progressive  dyspnoea. 

A  failing  or  intermittent  pulse. 

Cyanosis  showing  defective  oxygenation. 

Retraction  of  chest  wall  most  marked  at  epigastrium  or  at  the  clavicles. 

When  the  accessory  muscles  of  respiration  are  brought  into  play. 

When  the  child  is  compelled  to  sit  upright  in  order  to  breathe  and 
pulls  at  its  neck  and  throws  itself  from  side  to  side,  gasping  for  breath. 

Indications  for  Intubation.^ — "The  indications  for  intubation  are 
marked  In'  a  more  or  less  sinking  in  of  the  yielding  portions  of  the  chest, 
lower  ribs  and  sternum,  episternal  notch,  and  supra-clavicular  regions  with 
inspiration.      It  means  simply  that  air  cannot  gain  entrance  to  the  lungs  in 

Table  No.  79.  —Diphtheria  Cases — Willard  Parker  Hospital. 


Year. 

No.  Tre-ted. 

Died. 

Mortal. ty 
Per  cent. 

Recov  ries 
Per  cent. 

Intubations. 

Recover-     Recoveries 
Inch?sive.      P"  <=«"*• 

1901 

919 

275 

29.92 

70.  OS 

222 

70 

31  53 

1902 

1112 

271 

24.37 

75.63 

258 

116 

44.92 

1903 

1281 

356 

27.79 

72.21 

352             123 

34.94 

1904 

1402 

356 

25  39 

74-61 

79.50 

410             193 

47. 

*1905 

478 

98 

20.50 

154 

86 

56. 

Total 

5192 

1356 

26.12 

73.88 

1396 

588 

42.13 

*On  account  of  rebuilding  the  Hospital,  no  patients  were  received  after  June  17th. 


From  O'Dwyer's  treatise  on  "Iiituhation'"  in  his  book.  "l)i|)lilh('iia  and  Croup. 


1889. 


580  THE  INFECTIOUS  DISEASES. 

Table  No.  80. — fitatixtirs  of  fntiibatii/ii  Cases,  iit  the  M'illdid  J'urlcr  Ho.'<pita1. 


1J)01 


Month.     'Discharged.'       Died. 


Jan. 

Feb. 

March 

April 

May 

June 

July 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 


Total 


00 


15 
11 
17 
15 
13 
10 
10 
12 
13 
9 
13 
20 


158 


Per  cent. 
Recover  es 


11.76 
15  38 
32.00 
28.57 
35.00 
28.57 
16.67 
29.41 
23.52 
47  05 
40.90 
25.92 


334.75 


G.^neral  Average  of  Kecoveries  for  1901, 
27.89. 


Month. 


Jan. 

Feb. 

Ma  cli 

April 

May 

June 

July 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 


To'al.    . 


1902. 


Dl.scharged. 

D:ed.       ' 

1 

11 

10 

10 

10 

12 

20 

18 

28 

4 

14 

17 

10 

1 

9 

5 

8 

8 

7 

6 

;; 

9 

11 

13 

14 

114 

144 

Per  cent 
Recoveries 


52.38 
50.00 
37  50 
39.13 
22.22 
62.96 
10.00 
38.46 
53.33 
66.67 
45.60 
48.15 


525.80 


General  Average  of  Kecoveries  for  1902, 
43.81. 


Improvement  in  1902  over  1901,  15.92  per  cent. 


sufficient  quantity  to  fill  the  partial  vacuum  created  by  the  expansion  of  the 
chest,  and  the  wall  recedes  under  the  weight  of  the  atmospliere.  It  is  very 
marked  in  very  young  or  rachitic  children  owing  to  the  greater  elasticity  of 
the  ribs.  But  it  should  be  remembered  that  this  condition  is  not  peculiar 
to  stenosis  of  the  larynx  and  trachea,  as  it  is  produced  to  a  lesser  degree  by 
obstruction  in  any  part  of  the  respiratory  tract  that  interferes  with  the 
free  inflation  of  the  lungs.  It  is  found  in  caj  illary  bronchitis,  extensive 
deposits  of  ])seudo-2nembrane  in  the  bronchi,  atelectasis,  and  to  some  extent 
even  in  bronclio-pneumonia.  liccessioi's  at  the  root  of  the  neck  are  more 
significant  tlian  tliose  below,  as  the  violent  contractions  of  the  diapliragm 
aid  in  drawing  in  the  free  border  of  the  ribs  and  sternum. 

"When  recessions  are  marked  there  is  little  or  no  respiratory  murmur 
over  the  posterior  portion  of  the  chest,  Init  this  symptom  is  not  always  avail- 
able owing  to  the  laryngeal  stridor. 

"Atelectasis  with  excessive  quantity  of  blood  in  the  lungs,  as  would 
naturally  be  expected,  is  the  result  of  death  from  obstruction  in  the 
larynx,  br.t  there  are  exceptions  to  this  rule,  and  these  organs  arc  occa- 
sionally found  distended  with  air  and  containing  less  than  the  normal 
amount  of  blood.  This  acute  general  emphysema,  which  produces  bulging 
of  the  parts  that  usually  recede,  is  caused  by  greater  impediment  to  expira- 
tion than  inspiration,  and  air  accumulates  in  the  lungs  in  the  same  manner 


INTUBATION. 


581 


Table  No    81. — The  Following  Table  Shows  the  Remits  from  Intubation  in  Cases  oj 
Laryngeal  D phtheria  Treated  at  the  Municipal  Hospital,  Philadelphia, 
from  1S94,  to  190-3,  Iiic  usive. 


Year. 

Intubated 
Cases. 

Deaths. 

Mortalitv 
Per  Cent. 

1894 

Without   antitoxin 

100 

75 

75.00 

189.J 

About  50  per  cent,  received  antitoxin 

l-2-,>i 

<;7 

54.91 

189(3 

With  antitoxin      . 

1562 

94 

60  25 

1897 

1(                     u 

182 

127 

69.78 

1898 

41                           li 

149 

104 

69.99 

1899 

1(                        U 

165 

97 

58.78 

1900 

(  >                     u 

203 

111 

54.95 

1901 

u                 u 

139 

66 

47.47 

1902 

(1                 ii 

110 

54 

49.09 

1903 

"          "       

110 

55 

50  00 

Total 

■  •  • 

1435 

850 

59  23 

'  (  f  those  who  received  antitoxin  th.;  death  rate  was  52.94  per  cent. 
"21  per  cent,  of  this  number  did  not  receive  antitoxin. 


as  in  spasmodic  asthma.  It  is  not  common  in  croup,  ])iit  is  worth  remem- 
bering.     It  is  also  occasionally  found  in  capilhiry  bronchitis. 

"The  downward  movement  of  the  laryn.x  with  inspiration  is  pathogenic 
of  serious  obstruction  in  tliis  organ,  and  is  also  the  result  of  atmospheric 
l)ressure,  the  air  being  prevented  from  entering  with  sufficient  rapidity  to  fill 
the  partial  vaccuum  below.  It  is  readily  detected  in  adults,  but  not  so 
in  children,  owing  to  deoj)er  situation  of  the  larynx  in  the  latter. 

''This  symptom  is  not  present  in  stenosis  of  the  trachea,  owing  to  the 
great  elasticity  of  this  tube,  which  permits  of  considerable  motion  on  itself 
without  dis})lacing  the  laryn.x. 

"Abiding  cyanosis  is  too  late  a  symptom  to  wait  for,  and  besides,  it  is 
uncertain,  as  fatal  ol)struction  may  exist  in  the  glottis  with  extreme  pallor 
on  the  surface.  This  pallor  of  asphyxia  is  produced  by  the  excessive 
quantity  of  blood  drawn  into  and  stored  in  tiie  lungs  by  the  cupping-glass 
action  of  inspiration  when  the  air  is  almost  excludcil.      The  l)lood  in  the 


582 


THE   INFECTIOUS  DISEASES. 


cutaneous  capillaries  is  thus  reduced  to  a  miuimuni,  and  this,  although 
liighlv  charged  with  carbonic  acid,  only  serves  to  increase  the  paleness,  on 
the  principle  that  the  addition  of  a  little  blue  makes  a  clearer  white. 


Table  No.  83. —  The  Followiixj  Table  Shmcs  the  Canes  and  Mortality  of  Diphtheria 

{Including  Memhran  ms  Croup)   in  the  Municipal  Hospit  l,^  Philadcljihi', 

from  1890  o  19  3,  Inclunivc. 


PRE-ANTITOXTN  PEEinn. 

Year. 

Cases. 

Deaths, 
3 

Mortality — Per  Cent. 

1890 

12 

25.03 

1891 

29 

1 

3.44 

1892 

183 

48 

26.22 

18J3 

217 

62 

28.57 

1894 

465 

154 

33.12 

Total 

906 

268 

29.58 

ANTITOXIN  PERIOD. 


Year. 

Cases. 

Deaths. 

Mortality— Per  Cent. 

1895 

706 

190 

26.91 

lH9fi 

869 

193 

22.2 

1897 

1295 

310 

23.16 

1898 

12-29 

297 

24.16 

1899 

1373 

275 

CO.Oi 

1900 

1299 

264 

20.31 

1901 

889 

174 

19.57 

1902 

601 

137 
170 

22.79 

1903 

746 
9007 

22.78 

Total 

2000 

22.2 

1 1  am  indebted  to  Dr.  Welch  for  above  statistics. 


INTUBATION. 


583 


Table  No.  83  — Cases  of  Diphtheria  Treated  at  the  Coston  City  Hospital. 

CASES   TREATED    WITHOUT    ANTITOXIN. 


Year. 

No. 
Treated. 

Died. 

Jforfality 
Ter  cent. 

Recoveries 
Per  cent. 

Intubations. 

RecoTcries 
J'er  cent. 

Calendar 

"       1889 
1890 

"     1891-22 
1892-3 
1893-4 
1894-5 

529 
415 
237 

239 

45.17 

54.82 

128 

18.75 

Years 

151 

36.38 

63.61 

93 

15.05 

105 

44  30 

55.69 

50 

16.00 

387 

185 

47.80 
48.44 

52.19 

65 

13.84 

Financial 
Years       -{ 

419 

203 

51.55 

109 

17  43 

098 

263 

38.10 

61.89 

89 

16.85 

Feb.  1 

I  o  Sept.  1 

1895 

Total 

6113 

111 

18.16 

81.83 

39 

28.20 

3296 

1200 

38.22 

61.77 

573 

17.45 

CASES 

TREATED 

WITH   ANTITOXIN. 

Year. 

No. 
Treated. 

DieJ. 

Mortality 
Per  cent. 

Recoveries 
J'er  cent. 

Intubations 

Recoveries 
Ptr  cent. 

Sept.  1  to 
Jan.  31 
1895-6* 

1896-7 

1 -97-8 

1698 

1899 

1900 

844 

96 

11.37 

88.62 

79 

54.43 

Years 

1889 
13H7 

817 

276 

HI 
97 

14.61 

85.38 
86.95 

224 

35  26 

13.04 
11.87 

146 

54.11 

88.12 

171 

40.84 

1621 

162 

9.99 

90.00 

192 

67.18 

2547 
1576 
1008 

293 

11.50 
11.73 

88.49 

259 
184 

66.40 

Caleiulai- 
Years 

1901 
1902 

185 
111 

88.26 

68.47 

10.20 

89.79 

145 

66.20 

1903 
Total 

1179 

12868 

138 
1539 

11.70 
11.95 

88.29 

139 

73.38 

88.04 

1439 

59.54 

'  I  am  indebted  to  Dr.  McOdluni  for  above  statistics. 

'Thirteen  nionth.s  included  in  year  l«91-2. 

^  Some  of  these  patients  receive;!  aiiiitoxin,  liut  how  in  my  it  is  iiupossilile  to  say.  Th!s  explains  the 
comparatively  low  death-rate  from  Feb.  1,  189)  to  8ept.  I,  1895. 

*  From  Sept.  I,  189.5,  at  which  time  the  South  Department  was  o;  ened,  to  Dec.  31,  1903,  every  patient 
ill  with  diphtheria  recei'  ed  autiloxiri. 


584 


THE   INFECTIOUS  DISEASES. 


"The  temporary  cyanosis  which  eonies  and  goes  with  the  paroxysmal 
dyspnoea  of  the  second  stage  of  croup  is  of  no  particuhir  significance. 
Children  seldom  remain  long  in  one  position  ichen  suffering  severehj  from 
want  of  breath,  and  continued  restlessness,  if  consciousness  he  unimpaired, 
is  therefore  an  important  indication  that  it  is  time  to  afford  relief. 


iO. 


EBC 


!!SP?fBTf5?Sfr 


^T 


y 


Fig.  177. — lutrodueer  with  Tube  Attached. 


Fig.  178. — Introducer  with  Tube  and  Detached  Obturator. 


Fig.  179. — Introducer  Holding  Foreign  Body  Tube. 


"As  far  as  the  necessity  for  intuhation  is  concerned,  it  matters  little 
as  to  the  real  nature  of  the  ol)struction,  ])rovided  it  be  in  the  hirynx  and  not 
a  foreign  l)ody.  Tt  may  be  croup,  simple  laryngitis,  csdema  of  the  glottis, 
paralysis,  spasm,  or  even  a  neoplasm.     In  the  latter  it  will  tide  over  the 


INTLBATiON. 


585 


Fig.  180.— Extubator. 


Fig.  181. — Built  up  Tubes  for  Granulation  Tissue.     Useful  for 
treatment  of  "Retained  Tubes." 


Fig.  182.— Fischer's  Corrugated  Rubber  Tube  to  be  Used  for  Intra-laryngeal 
Medication  in  Chronic  Stenosis   (Occurring  Stenosis). 


586 


THE   INFECTIOUS  DISEASES. 


iiiiiiicdiatc  clanger  of  asphyxia,  and  leave  more  hrcathing  room  to  facilitate 
the  radical  operation." 

Dorsal  Method  of  Intubation. — This  method  is  the  most  convenient  as 
it  does  awa}'  with  the  necessity  of  several  assistants.  I  have  frequently  in- 
tubated in  the  dorsal  position  without  any  assistant.  This  method  appeals 
to  me  as  very  valuable  in  emergencies,  especially  so  when  a  physician  is 
called  out  of  town  where  no  trained  as^sistant  is  available.  The  method  of 
introducing  the  tube  is  the  same  as  that  described  as  the  O'Dwyer  method. 
Tlie  dorsal  method  has  been  advocated  by  the  attending  and  resident  statf 
at  the  Willard  Parker  Hospital  and  is  the  method  employed  there  by  Dr. 
Burckhalter,  Dr.  Lynah,  and   Dr.  Throne. 

The  gag  should  be  inserted  in  the  left  side  of  the  mouth,  and  slowly 
opened.  The  trained  nurse  steadies  the  child's  head  and  holds  the  gag  in 
place.  Witii  the  child  flat  on  its  back,  the  hands  firmly  held  by  a  blanket 
encircling  the  body,  the  ])hysician  stands  on  the  right  side  of  the  child  and 


JHHj 

^^^^^^t^W. 

■■ 

1 

■ 

^ 

tf^^'' 

nHJHHI 

WKKtUk^m. 

ul~~13 

■ 

nm^H 

/ 

\ 

^»- *-_J 

n^  ' 

. 

**"• 

^ 

'^  '^fl 

^ 

^ 

K^ 

^ 

m 

Fig.  ]8.3.' — Tlie  Mummy  liaiulage,  showing  child  in  proper  position  for 
the  dorsal  method  of  Intubation.  All  instruments  required  are  carefully 
arranged.      (Original.) 


introduces  the  index  finger  of  liis  left  hand  in  tlie  median  line  until  the 
ej)iglottis  is  felt.  The  epiglottis  should  be  raised  and  fixed.  The  tube 
should  then  be  guided  with  the  right  hand  of  the  operator,  a^ong  the  left 
index  finger  and  inserted  into  th(>  cul-de-sac  of  the  larynx.  It  would  be 
j)rofitable  to  read  O'Dwyer's  description  of  the  method  of  intubation  which 
I  a])pend  here,  the  only  difference  being  that  O'Dwyer  recommends  the  sit- 
ting position,  whereas  T  advocate  the  dorsal  position. 

Upright  Method  of  Operating. — "The  nuise  or  person  who  holds  the 


'The  set  of  photographs  illustrating  Intubation,  Extul)ation,  and  Gavage  were  taken 
in  the  wards  of  the  Willard  I'arker  Hospital-  I  am  inde))ted  to  Miss  Henry,  the  super- 
vising nurse,  Miss  Dunwoodie,  the  head  nurse,  and  Dr.  T.  De  L.  Burckhalter  and  Dr. 
Lynah, the  resident  and  assistant  resident  physiciaiis,  for  their  uniform  courtesy  and  kind 
assistance  with  my  illustrations  and  clinical  details. 


Fi„     184 —Intubation.     First    step    in    operation:     The   handle    ot    introdueer 
parallel'to  the  body  axis;  the  top  of  the  tube  just  entering  the  Larynx.      (Original. ) 


Fvr    ib,3.    -Intubation.     S.-„„d  ^l.].  m  ..,M.n.tiu„;    Handle  ul   n.tnxlu.rr  elcvatMr 
the  tube  sinking  into  huynx  as  the  luindle  of  introducer  is  elevated.      (Original). 

(587j 


I 


588  THE  INFECTIOUS  DISEASES. 

child  should  be  seated  on  a  solid  chair  with  a  low  back,  and  the  patient 
placed  on  the  lap  with  head  resting  on  left  shoulder  of  nurse  in  order  to 
leave  the  gag  free.  The  hands  can  either  be  held  or,  still  better,  secured  by 
the  sides,  by  a  towel  or  sheet  passed  around  the  body  and  left  in  that 
position  until  the  tube  is  inserted  and  the  string  removed.  Fastening  the 
hands  in  front  of  the  chest  or  thick  garments  in  the  same  location  renders 
it  more  difficult  to  depress  the  handle  of  the  introducer  sufficiently  to  carry 
the  tube  over  the  dorsum  of  the  tongue. 

"The  gag  is  then  inserted  well  back  behind  or  between  the  teeth  in  the 
loft  angle  of  the  mouth  and  opened  widely,  care  being  taken  not  to  do  it 
too  suddenly  or  to  use  too  much  force.  In  children  who  have  not  at  least 
one  bicuspid  on  the  left  side,  the  gag  should  not  be  used,  as  it  slips  forward 
on  the  gums,  and,  besides  being  in  the  way,  is  liable  to  injure  the  incisor 
teeth.  There  is  little  difficulty  in  these  cases  in  keeping  the  mouth  suffi- 
ciently open  Avith  the  finger,  if  carried  far  enough  to  the  patient's  right 
to  be  out  of  range  of  the  front  teeth.  Allowing  the  child  to  compress  the 
finger  between  the  gums  for  a  few  seconds  until  the  jaws  relax,  before  carry- 
ing it  into  the  fauces,  avoids  the  necessity  for  using  force. 

"An  assistant  stands  behind  the  patient  and  holds  the  head  firmly  by 
placing  one  hand  on  either  side,  and  at  the  same  time  slightly  elevates  the 
chin.  The  operator  stands  in  front  of  the  patient,  holding  the  introducer 
lightly  between  the  thumb  and  fingers  of  the  right  hand,  the  thumb  resting 
on  the  upper  surface  of  the  handle,  just  behind  the  knob  that  serves  to 
detach  the  tube,  and  the  index  finger  in  front  of  the  trigger  support  under- 
neath. Held  in  this  manner  it  is  impossible  to  use  force  enough  to  make 
a  false  passage,  while  if  firmly  grasped  in  the  hand  the  beginner  may,  uncon- 
sciously, exert  sufficient  force  to  lacerate  the  tissues. 

"The  index  finger  of  the  left  hand  is  carried  well  down  in  the  pharynx 
or  beginning  of  oesophagus  and  then  brought  forward  in  the  median  line, 
raising  and  fixing  the  epiglottis,  while  the  tube  is  guided  along  beside  it  into 
the  larynx.  If  any  difficulty  is  experienced  in  locating  the  epiglottis,  it  is 
better  to  search  for  the  cavity  of  the  larynx,  a  cul-de-sac  into  which  the  tip 
of  the  finger  readily  enters,  and  which  cannot  be  mistaken  for  anything  else. 
Once  in  this  cavity  the  epiglottis  must  be  in  front  of  the  finger  and  the  latter 
is  then  raised  and  pressed  toward  the  patient's  right  to  leave  room  for  the 
tube  to  pass  beside  it.  The  distal  extremity  of  the  tube  should  be  kept  in 
contact  with  the  finger,  and  even  directing  it  a  little  obliquely  toward  the 
right  side  of  the  larynx  if  necessary  to  get  inside  the  left  aryepiglottic  fold, 
especially  in  very  young  children.  The  handle  of  the  introducer  is  held 
close  to  the  patient's  chest  in  the  beginning  of  the  operation,  and  rapidly 
raised  as  soon  as  the  end  of  the  tube  has  passed  Ijehind  the  epiglottis,  other- 
,wise  it  will  slip  over  the  larynx  into  the  oesophagus. 

"Some  operators  hold  the  introducing  instrument  in  the  horizontal 


...S^,^Ss^s.;--aS:ns-°^--^^^ 


,,|^,    187  -Extvibabion.  Second  step  in  the  operation 
holding  the  tube  firmly  ;  the  operator  withdraws  the  lube. 


The  beak  of   the  extractor 
(Original.) 

^  (589) 


590  THE  INFECTIOUS  DISEASES. 

position  until  the  tube  is  well  back  in  the  fauces,  and  th(>n  swing  it  around 
to  the  middle  line  and  complete  tlie  operation  in  tlie  usual  manner.  The 
beginner  is  liable  to  forget  the  latter  movement,  wliich  is  the  only  objection 
to  this  plan. 

"As  soon  as  the  cannula  is  inserted  the  introducer  with  obturator  at- 
tached is  withdrawn  by  pressing  forward  tlie  button  on  the  upper  surface 
of  the  handle  with  the  thumb,  while  counter-pressure  is  made  with  the 
index  finger  on  the  trigger  beneath.  In  removing  the  obturator — the  joint  in 
the  shank  of  which  is  intended  to  facilitate  this  part  of  the  operation — 
the  movements  required  for  insertion  are  reversed.  To  prevent  the  tube 
from  being  also  withdrawn,  the  finger  must  be  kept  in  contact  with  its 
shoulder  either  on  the  side  or  posteriorly. 

"The  tube  should  be  carried  well  down  in  the  larynx  before  detaching 
it,  otherwise  the  lower  aperture  will  be  left  open  and  liable  to  strip  off 
pseudo-membrane  as  it  is  subsequently  pushed  home  with  the  finger. 

"The  gag  is  removed  as  soon  as  the  tube  is  in  place,  but  the  string  is 
allowed  to  remain  in  place  long  enough  to  be  certain  that  the  dyspnoea  is 
relieved  and  that  no  loose  membrane  exists  in  the  lower  portion  of  the 
trachea.  In  some  cases  the  presence  of  the  thread  is  desirable  because  it 
excites  more  coughing,  which  is  necessary  to  expel  accunmlated  secretions 
and  to  inflate  any  collajise  of  the  lungs  that  may  have  taken  place.  In 
removing  the  string  the  finger  must  be  reinserted  to  hold  the  tube  down, 
Ijut  the  gag  is  rarely  necessary,  as  children  old  enough  to  understand  readily 
open  the  mouth  for  this  jjurpose.'' 

The  characterist'c  tubal  cough  due  to  a  rush  of  air  through  the  tube 
when  in  the  larynx,  if  once  heard  will  always  be  remembered.  Usually  the 
presence  of  the  tube  excites  a  paroxysm  of  coughing  and  large  quantities  of 
mucus  and  membrane  will  frequently  be  expelled.  The  effect  most  no- 
ticeable is  the  immediate  relief  of  the  laryngeal  stenosis.  It  is  wise  to  wait 
five  or  ten  minutes  before  withdrawing  the  silk  thread  that  has  been  placed 
in  the  tube.  After  cutting  the  thread  the  finger  should  again  be  placed 
over  the  head  of  the  tube,  and  the  tube  firmly  pressed  down  while  the  string 
is  withdrawn. 

There  are  several  important  }K)ints  which  must  be  emphasized  in  this 
operation.  In  the  first  place  no  force  is  necessary.  "Occasionally  a  mo- 
mentary spasm  retards  the  immediate  entry  of  the  tube  into  the  larynx,  in 
which  case  rather  than  use  force,  it  is  best  to  wait  a  second  or  two  for  this 
to  relax,  when  the  tube  will  fall  into  place  The  introducer  should  be  held 
lightly  between  the  end  of  the  thumb  and  finger,  and  not  grasped  firmly  in 
the  hand.  The  introducer  should  be  kept  exactly  in  the  middle  line,  other- 
wise the  obturator  will  pinch  in  the  caliber  of  the  tul)e  and  drag  the  latter 
with.it  as  it  is  withdrawn.  It  often  happens  that  the  child  manages  by  one 
effort  to  slip  down  in  the  nurse's  lap,  while  the  grasp  that  the  assistant 


INTUBATION. 


591 


exerts  tilts  tlic  head  back,  and  tlic  tube  may  impinge  on  the  posterior  wall  of 
the  larynx.  The  lines  and  ang'es  must  be  maint^iined  to  insure  (|uick 
intubation.  The  bic-k  of  observance  and  of  carelessness  in  these  points 
explain  many  failures  of  inexperienced  operators.  //  ihe  lube  is  not  properly 
placed  at  the  first  attempt,  it  is  better  to  begin  all  over,  mahing  repeated 
short  attempts,  if  necessanj.  rather  than  a  single  prolonged  one." 

Accidents  During  Intubation. — An  inexperienced  operator  will  fre- 
quently be  rewarded  by  fatal  asphyxia.  Prolonged  attempts  to  introduce 
the  tube  will  result  in  apncea. 


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Fig.  188. — T?abv  K.,  nursing  infant,  eleven  months  old,  snflFered  with 
Laryngeal  Di]>litlieiia  complicated  by  Bioncho-pnenmonia.  Stenosis  requiring 
intubation,  t'ase  seen  in  consultation  with  J)r.  Kahrs  in  Bronx.  Tube  re- 
mained in  larynx  nine  days.  Child  recovered.  Private  practice  case.  (Orig- 
inal.) 


"Ten  seconds  is  tlie  longest  lime  that  should  be  ()ccu])ied  in  each 
attempt,  if  the  child  is  suffering  from  urgent  dyspncpa  at  the  time.''  A 
cliild  cannot  breathe  while  the  finger  is  in  the  throat.  Repeated  attempts 
wi'l  so  exhaust  the  vitality  of  a  child  that  this  must  1)e  reckoned  with. 

"The  expert  seldom  requires  more  than  five  seconds  to  complete  the 
operation,  except  in  difficult  cases,  sucli  as  a  very  small  mouth  and  throat. 


592  THE   INFECTIOrS  DISEASES. 

marked  incroase  in  the  size  of  the  tonsils,  especially  if  chronic;  extreme 
tumefaction  of  the  e})i^lottis  and  arycpiglottic  fold,  which  changes  or  oh- 
literates  the  usual  hind  marks,  and  the  struggles  and  resistance  sometimes 
offered  by  older  children  when  intractable.  In  the  latter,  although  I  have 
never  had  to  resort  to  it,  the  aihithiistration  of  an  aiuesthetic  would  be  less 
injurious  than  the  exhaustion  and  cyanosis  induced  by  a  prolonged  struggle 
without  it. 

"If  the  tube  has  once  passed  on  the  outside  of  the  larynx,  and  this  is 
recognized  before  it  is  detached  from  the  obdurator,  it  is  useless  to  try  to 
rectify  the  position  without  first  depressing  the  handle  of  the  introducer  as 
in  the  beginning  of  the  operation,  because,  owing  to  the  length  of  the  tube, 
the  palate  arrests  the  upward  movement  before  the  distal  extremity  reaches 
the  level  of  the  glottic  opening. 

"In  croup  the  ventricles  of  the  larynx  are  usually  obliterated  by  swelling 
of  the  tissues  and  covered  over  by  the  pseudo-membrane,  and  therefore 
seldom  offer  any  obstacle  to  the  passage  of  the  tiibe  on  the  first  introduc- 
tion; but  when  the  stenosis  persists  longer  than  usual  and  reintroduction 
becomes  necessary,  it  is  well  to  remember  th.at  this  may  be  a  source  of  ob- 
struction. The  tube  once  having  entered  a  ventricle,  a  moderate  amount 
of  force  is  all  that  is  necessary  to  make  a  false  passage.  I  have  known  this 
accident  to  occur  when  the  oj)erator  was  unconscious  of  having  used  any  force 
whatever.  If  the  patient's  head  be  thrown  too  far  back,  the  tube  may  also 
be  arrested  by  coming  in  contact  with  the  anterior  wall  of  the  larynx  or 
trachea." 

An  accident,  which  fortunately  is  very  rare,  is  the  pushing  of  membrane 
downward.  In  this  condition  stenosis  will  not  be  relieved.  In  such  cases 
it  is  advisable  to  extubate  at  once,  and  to  reintubate  by  using  one  of  the 
specially  constructed  tuljcs. 

Specially  Constructed  Tubes  (see  Fig.  181). — Caliber  tubes,  made  of 
metal,  also  known  as  foreign  body  tubes,  have  a  nnich  wider  lumen  than 
the  ordinary  tubes  used  for  intubation.  They  are  also  shorter.  Through 
these  tubes  large  membranes  are  frequently  expelled.  There  are  instances, 
however,  where  large  ])seudo-membranes  extend  into  the  trachea  to  the 
smallest  ramifications  of  the  bronchi.  Violent  coughing  paroxysms  fre- 
quently dislodge  these  meiid)ranes,  so  that  distinct  caxis  of  the  trachea 
and  its  bifurcation  can  be  ])lainly  made  out.  Sev(>ral  of  these  casts  were 
seen  ])y  me  during  my  service;  at  the  Willard  Parker  Hospital. 

Intubation  in  Chronic  Stenosis  of  the  Larynx. — O'Dwyer's  rules  and 
indications  for  the  performance  of  intubation  in  chronic  laryngeal  stenosis, 
are  as  follows:  (1)  Cicatricial  stenos's,  due  to  injury  to  the  soft  parts  from 
syphilis,  irritants,  and  traumatism.  (2)  Narrowing  of  the  space  both  below 
and  above  the  vocal  bands  from  the  products  of  chronic  inflammati<m — 
simple,  tuberculous,  specific,  malignant,  or  otherwise,  and  including  such 


IMTUBATiON.  593 

conditions  as  the  so-called  pachydermia  laryugis,  and  corditis  vocalis  inferior 
liyi^ertrophica.  (3)  It  is  especially  valuable, in  cases  in  which  tracheotomy 
has  been  performed,  and,  when  the  tracheal  cannula  having  been  worn  for  a 
considerable  length  of  time,  the  upper  part  of  the  trachea  is  filled  with 
granulations  and  the  laryngeal  muscles  have  become  weakened  from  disease. 
In  this  condition  intubation  has  effected  many  brilliant  cures.  (4)  In 
papilloma  of  the  larynx  it  has  been  found  helpful  in  a  fair  proportion  of 
cases,  although  its  results  in  this  disease  are  less  satisfactory  than  in  most 
others  in  which  it  has  been  employed.  (5)  Deformities  of  the  larynx  from 
injury  or  disease  of  its  cartilaginous  framework,  which  have  resulted  in 
constriction  of  the  caliber  of  the  organ,  have  been  cured  by  it.  (6)  It  has 
also  been  used,  with  excellent  results,  in  anchylosis  of  the  crico-arytenoid 
articulations,  and  in  arthritis  deformans  of  the  same  part.  (7)  It  is  useful 
in  various  affections  of  the  nerves  of  the  larynx ;  for  instance,  in  hysterical 
contraction  of  the  abductors,  "aphonia  spastica." 

Edwin  RosenthaP  advises  a  spray  of  peroxide  of  hydrogen  as  a  pre- 
liminary to  intubation.  Eosenthal  does  not  believe  that  heart  failure, 
which  is  in  reality  toxsemia,  can  be  cured.  He  insists  on  cardiac  stimulants 
and  gives  strychnine  from  the  beginning,  in  increasing  doses. 

In  a  paper  published  by  W.  L.  Stowell,  the  following  statistics 
occur :  MacXaughton  and  Maddern  reported  5506  intubation  cases,  with  30 
per  cent,  of  recoveries.  Dillon  Brown  reported  27G  intubation  cases,  with 
calomel  fumigations,  and  49  per  cent,  of  recoveries.  The  collective  investi- 
gation of  the  American  Pediatric  Society  now  places  the  mortality  of 
laryngeal  diphtheria,  or  croup,  at  21  per  cent.;  and  in  intubated  cases  with 
antitoxin  at  27.24  per  cent. 

The  Tolerance  of  the  Larynx  for  the  Intubation  Tube. — I  have  fre- 
quently seen  children  walking  around  the  wards  of  the  Willard  Parker 
Hospital  who  have  worn  intubation  tubes  about  two  years.  When  one  con- 
siders the  anatomical  structure  of  the  larynx,  it  is  surprising  tliat  no 
inflammatory  condition  results  from  the  presence  of  this  foreign  body.  In 
the  chapter  on  "Bronclio-pneumonia"  I  report  a  case  of  diphtheria  com- 
plicated by  croup  and  later  by  broncho-pneumonia.  Intubation  was  re- 
quired for  the  relief  of  laryngeal  stenosis.  The  child  coughed  violently  and 
expelled  the  tube  so  frequently  that  the  case  had  in  all  twenty  intubations. 
The  case  finally  recovered. 

Utceraiions  due  to  the  intubation  tube  have  been  seen  by  me: — 

(1)  In  the  cricoid  division  of  the  larynx,  just  below  the  vocal  cords. 

(2)  At  the  base  of  the  epiglottis,  from  ])ressure  during  the  act  of 

swallowing. 

(3)  On  the  anterior  wall  of  tlie  (racliea  near  tlic  distal  end  of  the  tube. 


"^  Archives  of  Pediatiica,  June,  1903. 


594 


THE  INFECTIOUS  DISEASES. 


Ulcerations  resulting  from  an  iiitul)ation  tube  liave  been  seen  by  me 
post-mortem  in  children  that  were  fed  l)y  gavage.  I  liave  also  seen  ulcera- 
tion where  children  were  fed  by  the  natural  methods.  I  believe  that  feed- 
ing with  the  swallowing  movements  incidental  to  the  same  produces  ulcera- 
tion at  the  lower  end  of  the  tulje,  because  of  tlic  up  and  down  riding  of  tlie 
tube. 

A  post-mortem  specimen  of  larynx  and  trachea  was  recently  (October,  1904)  ex- 
amined by  me  at  the  Willard  Parker  Hospital.    The  child  was  in  the  hospital  twenty- 


].s!i. — (ravaj^c.     Method  used  in  Forced  Feeding  at  the  Willard  Parker 
Hospital.     (Original.) 


one  days,  it  was  therefore  an  acute  laryngeal  stenosis.  Three  ulcerations  e.xisted 
at  the  cricoid  cartilage  and  nine  other  ulcerations  existed  at  the  distal  end  of  the 
tube. 

Feeding  After  Intubation. — A'arious  methods  of  feeding  are  in  vogue, 
and  each  clinical  observer  seems  to  I)e  satisfied  with  his  particular  method. 
Whenever  possible  we  should  try  to  resort  to  the  usual  mouth  feeding.  I 
invariably  feed  semi-solid  food,  such  as  bread  soaked  in  milk,  custard,  junket, 
cornstarch,  or  rice  pudding,  soft  boiled  eggs,  if  the  child's  age  warrants  it; 
also  concentrated  soups  and  broths,  calfsfoot  or  chicken-jelly,  water  ices 


IXTIBATIOX. 


595 


and  ice  cream.  These  articles  of  food  I  have  found  best  adapted  in  a  very 
extensive  experience  in  hospital  and  consultation  practice. 

In  very  young  infants,  breast  or  bottle-fed,  great  care  should  be  exer- 
cised with  the  feeding.  If  a  breast-fed  child  refuses  to  nurse,  the  breast- 
milk  can  be  pumped  off  and  the  infant  fed  every  three  or  four  hours  by 
spoon. 

]\Iy  advice  in  intubated  cases:  Use  natural  methods  of  feeding — do 
not  use  gavage — choose  simple  ways.  Eectal  feeding  may  be  tried  if 
vomit J no;  occurs. 


Fig.    1!M). — Casselherry  Method  of  Feeding.      (Original.) 

The  Casselhcrry  method  of  feeding  consists  in  laying  the  child  flat  on 
its  back  across  the  nurse's  lap,  with  the  head  below  the  level  of  the  body.  By 
this  means  we  avoid  introducing  liquids  into  the  lar3^nx. 


Intubation  in  Private  Practice. 

The  management  of  a  case  of  intul)ation  in  private  practice  should  be 
carefully  considered.  Xo  child  should  be  permitted  to  wear  a  tube  in  the 
larynx  without  the  constant  supervision  of  a  trained  nurse.  In  the  Willard 
Parker  Hospital  we  have  competent  trained  nurses  both  night  and  day,  and 
a  physician  is  always  ready  to  respond  in  case  of  emergency.      I  have  fre- 


596 


THE   INFECTIOUS  DISEASES. 


quently  intubated  in  i)rivate  practice  and  always  give  the  following  orders 
to  the  trained  nurse: — 

Fiml. — 11'  the  breathing  l)ec()nies  labored  or  if  the  child  has  a  suildeii 
increase  in  the  number  of  respirations,  notify  the  physician  at  once. 

Second. — Watch  the  pulse;  a  sudden  increase  in  the  pulse-rate  or  a 
sudden  intermittent  pulse  means  danger. 

Third. — If  cyanosis  or  sudden  apncca  occurs,  possibly  caused  ])y  a 
plugging  of  the  lower  portion  of  the  tube  with  membrane,  notify  the  physi- 
cian so  that  the  tube  can  be  extubated  and  a  tube  of  larger  caliber  inserted. 

Fourth. — If  the  tube  is  sud- 
denly expelled  during  a  paroxysm 
of  coughing  (auto-extubation),  a 
hurry  call  should  be  sent  to  the  phy- 
sician. 

What  to  Do  in  an  Emergency. 
Firnt. — Give  a  mustard  foot-bath 
or  apply  a  niustnrd  plaster  over  the 
heart  to  stimulate  the  circulation. 

Second. — Give  5  to  10  drops  of 
aromatic  spirits  of  ammonia  with  an 
equal  quantity  of  whisky.  Nitro- 
glycerine can  be  given  in  V^oo-grain 
doses  every  hour,  hypodermically  if 
necessary. 

Thud. — Relieve  the  stenosis,  if 
it  exists,  by  careful  intubation. 

Fourth. — If  an  expert  intuba- 
tor  is  not  at  hand,  or  if  intubation 
pushes  membrane  downward  so  that 
the  stenosis  persists,  resort  to  trache- 
otomy. 

Regarding  extubation,  my  rule 
in  private  practice  is  to  extubate  on 
the  fifth  day,  or  on  the  morning  of 
the  sixth  day,  provided  the  tempera- 
ture is  normal  and  no  complication 
exists.  It  is  safer  to  leave  a  tube  in 
the  larynx  one  day  longer  rather 
than  risl-  the  necessity  of  reintuha- 
lion. 

IMiiTnif  B.,  2  years  old,  was  seen  by 

Fig.  191. — Tomporiitiirc  f'liart  from  me  tliroii<rh  the  courtesy  of  the  atten(li:i<i; 

a    Case    of    Diphtheria:      Croup,    In-  physician.Dr. H. Weinstein,  on  the  s  eond 

tubation.     (Original.)  day  of  her  illness.      There  were  patches 


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INTUBATION.  597 

of  diphtheria  visible  on  the  pharynx  and  tonsils.  The  temperature  was  101 '-/°  F., 
pulse  140.  There  was  also  laryngeal  l/.volvement  noticeable  by  the  croupy  cough. 
An  injection  of  2000  units  of  antitoxin  was  first  given.  The  colon  was  flushed  and 
the  bowels  thoroughly  emptied.  A  dose  of  calomel  was  given  and  milk  and 
albumin  watev  ordered,  for  the  diet. 

Xasal  irrigatiuiis-  of  saline  solution  were  ordered  every  two  hoiu-s.  An  ice-bag 
was  apjilied  to  the  neck.  On  the  third  day  the  temperature  rose  to  102°  F.,  pulse 
130,  respiration  36.  Breathing  labored — considerable  retraction  of  the  chest — cough 
very  croupy.  Large  quantities  of  mucus  were  expectorated.  The  pulse  was  146, 
respiration  40.  Stimulation  was  demanded  and  1  drachm  of  whisky  was  given 
every  liour.  Laryngeal  stenosis  was  so  severe  that  a  liurry  call  was  sent  to  me  to 
intubate.  The  child  was  quickly  intubated.  A  No.  3  rubber  tube  having  a  coating 
of  gelatine  and  alum  was  inserted.  The  stenosis  was  immediately  relieved.  The 
child  appeared  comfortable  and  fell  asleep.  Six  hours  after  the  intubation  the  tem- 
2>erature  was  103°  F.,  pulse  140,  respiration  40.  Cold  sponging  was  ordered  and 
owing  to  severe  coughing  when  liquids  were  given,  semi-solids  were  ordered  while 
the  intubation  tube  was  in  situ.  On  the  following  day  the  temperature  dropped  to 
101.6°  F.,  and  on  the  third  day  after  intubation  the  child  was  practically  normal. 
The  tube  was  left  in  the  larynx  five  days,  and  as  soon  a.s  the  temperature  dropped 
to  99°  F.  the  child  was  extubated.  The  patient  made  an  uneventful  recoverj\  No 
complications  followed.  I  might  add  that  the  usiutI  rule  of  adininistering  15  grains 
of  bromide  of  sodium  or  V12  gi'ain  of  sulphate  of  morphine,  as  an  anti-spasmodic  one 
liour  before  extubation,  was  not  given  in  this  case. 

A  Study  of  the  Coxditiox  of  the  Upper  Air  Passages  Before  and 

After  Intubation  of  the  Larynx.      Also,  an  Inquiry  Into 

THE  Method  of  Feeding  Employed  in  the  Cases.^ 

Laryngeal  stenos's  will  frequently  be  relieved  after  one  intubation  and 
one  extubation.  There  are  other  cases  which  require  several  intubations 
before  a  permanent  cure  results. 

I  have  examined  a  series  of  children  that  were  operated  upon  several 
years  ago.  Two  classes  of  cases  have  been  selected.  One  series  was  seen  at 
the  Willard  Parker  Hospital,  and  the  cases  were  intubated  by  the  resident  or 
assistant  resident  physician.  The  cases  in  this  series  cover  the  years  189G  to 
1900.  and  were  under  treatment  of  Dr.  E.  G.  Bryant  and  Dr.  Somerset. 

First  Series.  Children  Intubated  in  the  Hospital. — The  children  ad- 
mitted to  the  Willard  Parker  Hospital  belong,  as  a  rule,  to  the  laboring 
class  of  people.  Exceptionally,  the  service  at  the  hospital  receives  patients 
of  a  better  class.  All  of  the  children  examined  l)y  me  belonged  to  the  tene- 
ment house  district  of  New  York  City.  The  houses  are  densely  crowded 
tenements  having  a  minimum  quantity  of  fresh  air  and  sunlight.  It  is 
not  unusual  to  see  cases  from  such  unsanitar}^  surroundings  ending  fatally. 
These  children  arc,  as  a  rule,  very  anjumic  and  are  extremely  susceptible  to 
infection. 


'  Pajier  read  before  the  International  iledical  Congress  held  at  Madrid^  Spain, 
April  20,  1903. 


598 


THE  INFECTIOUS  DISEASES. 


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INTUBATION.  599 

Hospital  Cases:      10. 
8  cases  required,  one      intubation 
1  case     required  three  intubations 
1  case     required  four    intubations 

Day  of  the  Disease. 
4  cases  were  intubated  on  the     '2d     day  of  illness 

1  case    was    intubated  on  the     3d     day  of  illness 

2  cases  were  intubated  on  the  4th  day  of  illness 
1  case  was  intubated  on.  the  5th  day  of  illness 
1  case  was  intubated  on  the  9th  day  of  illness 
1  case     was    intubated  on  the  14th  day  of  illness 

One  case  intubated  seven  years  ago  has  had  no  ilhiess  since.  Four 
cases  intubated  six  years  ago  are  in  excellent  health  to-day.  One  case  has 
remained  entirely  well.  One  case  had  enlarged  cervical  lymph  nodes.  One 
case  had  pneumonia  one  year  later.  One  case  had  pneumonia  and  paralysis 
and  five  years  later  had  a  second  attack  of  diphtheria,  but  no  laryngeal 
stenosis. 

Five  cases  intubated  three  years  ago  are  in  good  condition  to-day. 
Tliree  had  measles  and  bronchitis  after  recovery.  .  One  has  not  had  a 
day's  illness  since  intubation.  One  case  had  a  mild  attack  of  croup  two 
years  after  intubation,  but  did  not  require  reintubation. 

Rachitis  seems  to  play  an  important  part  in  the  causation  of  laryngeal 
stenosis,  just  as  we  know  that  rickets  is  met  with  in  laryngismus  stridulus. 
Eight  cases  out  of  the  10  reported  in  this  series  showed  some  form  of 
rickets. 

There  seems  to  be  a  certain  predisposition  for  the  development  of 
laryngeal  stenosis  in  children  affected  with  diphtheria  who  are  rachitic. 

Condition  of  the  Throat. — In  all  of  the  cases  of  this  series  some  form 
of  chronic  tonsillar  or  pharyngeal  condition  was  found.  Adenoids  were  also 
seen  in  3  of  these  cases.  Whether  or  no  the  hypertrophied  tonsils  seen  in 
these  cases  were  present  at  the  time  of  intubation  is  not  known.  The  fact 
that  8  cases  out  of  10  still  showed  enlarged  tonsils,  and  1  case,  which  makes 
!>  cases,  reported  having  had  a  tonsillotomy  performed,  proves  that  hyper- 
trophied tonsils  nnist  liave  menaced  the  children's  health  before  the  diph- 
theria. 

Feedinr/  Duriiif/  Infinici/. — It  is  certainly  an  interesting  fact  that  all 
of  the  children  in  tliis  series  were  breast-fed.  When  abnormal  conditions, 
as  rickets,  scurvy,  tuberculosis,  syphilis.'  or  otlier  undermining  disorders 
exist,  then  recurring  stenosis  of  the  larynx  might  possibly  be  provoked  by 
such  chronic  disease. 


^Read  article  on  "Syphilitic  Stenosis  of  the  Larynx"  in  chapter  on  "Syphilis,'' 
page  720. 


600  THE  INFECTIOUS  DISEASES. 

These  cases  of  recurring  stenosis  sometimes  require  months  and,  in 
rare  instances,  years  of  intubating  until  recovery  takes  place.  I  have  seen 
at  least  6  chronic  tube  cases  while  making  my  rounds  in  the  wards  at  the 
AVillard  Parker  Hospital.  Intubation  ha^^.  in  America,  entirely  replaced 
tracheotomy  for  the  relief  of  acute  laryngeal  stenosis.  Eubber  tubes  are 
used  exclusively  for  intubation.  The  old  metallic  tubes  have  long  ago  been 
discarded.  Tracheotomy  is  used  as  a  secondary  operation,  usually  to  cure 
"retained  tubes."  When  laryngeal  stenosis  persists  and  the  patient  cannot 
get  along  without  the  tube  then  a  tracheotomy  is  resorted  to. 

A  very  interesting  series  of  papers,  descr'bing  the  above  condition,  has 
been  puljlished  by  J.  Rogers,  Jr.,  under  the  title  of  "Postdiphtheritic 
Stenosis  of  the  Larynx"  (Retained  Intubation  Instruments  and  Retained 
Tracheal  Cannulae). 

Rogers  says :  "The  commonest  cause  of  postdiphtheritic  stenosis  neces- 
sitating long-continued  intubation  is  a  hypertrophy  of  the  sul)glottic  tissues 
accompanied  l)y  a  chronic  inflammation.  The  intul^ation  is  in  no  way  the 
cause  of  this,  as  it  occurs  irrespective  of  the  operation.  Less  often  there  is 
an  ulceration,  and  siihseqaently  a  formation  of  a  greater  or  less  amount  of. 
cicatricial  tissue,  and  contraction.  This  likewise  is  not  the  result  of  the  in- 
tubation except  in  rare,  and  practically  unavoidable,  instances.  But  it 
certainly  may  follow  a  tracheotomy,  and  in  a  larynx,  already  chronically 
stenosed,  it  makes  the  condition  worse,  but  not  necessarily  more  difficult  to 
cure.  Exuberant  granulations  within  the  larynx  apparently  do  not  occur 
u-ith  intubation,  no.  matter  how  prolonged.  I  should  add  that  in  a  recently 
published  book  on  'Tubage  et  Tracheotomie  en  dehors  du  Croup.'  by  Antoine 
Sargnon,  of  Lyon,  France,  a  half-dozen  more  cases  of  retained  tubes  are 
cited,  in  which  ulceration  and  cicatrizat'on  are  mentioned  as  causes  of  the 
stenosis,  but  without  details :  and,  as  I  could  not  find  the  original  refer- 
ences, I  cannot  well  discuss  them." 

The  frequency  of  the  occurrence  of  a  postdiphtheritic  stenosis  accom- 
panying intubation  is  a  matter  of  some  interest.  Dillon  Brown  says  that 
he  has  encountered  it  about  once  in  every  75  or  100  cases. 

C.  G.  Jennings,  of  Detroit,  with  an  equally  large  experience,  says  that 
he  has  never  met  with  the  severer  forms  of  the  difficulty,  but  that  in  two  or 
three  instances  he  has  had  to  continue  the  intubation  as  late  as  the  third 
week  after  the  first  insertion,  before  recovery  was  complete.  His  associate, 
Shurley,  has  never  had  any  trouble  with  delay  in  the  removal  of  the  tube. 
Galatti,  in  the  article  above  referred  to,  states  that  he  had  3  chronic 
stenoses  in  31  intubations.  He  reports  Ranke  as  having  had  1  case  in  many 
hundred ;  Heuhner,  1  in  250,  and  Bokay  2  in  800.  George  McNaughton, 
of  Brooklyn,  says  that  he  has  had  but  few  cases  in  many  hundred,  and  these 
recovered  at  the  latest  within  several  weeks. 

At  the  Nursery  and  Child's  Hospital  of  New  York  City  there  have  been 


INTUBATION. 


601 


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002  THE   INFECTIOUS  DISEASES. 

110  noticeably  prolonged  intubations.  The  New  York  Foundling  Hospital 
has  had  6  eases  in  a  total  of  approximately  500.  Investigation  of  the  statis- 
tics at  this  institution  forcibly  illustrates  the  advantages  in  the  use  of 
the  diphtheria  antitoxin.  The  house  physician  complained  to  Dr.  Eogers 
that  before  the  introduction  of  this  remedy  his  predecessors  had  alway?^ 
averaged  at  least  one  intubation  a  week^  and  thereby  obtained  much  valuable 
experience;  but  about  the  time  he  came  into  the  hospital,  the  rule  was 
instituted  that  antitoxin  should  be  given  to  very  patient  as  soon  as  there  was 
any  suspicion  of  diphtheria.  The  result  was  that  he  had  never  in  a  year's 
service  had  a  single  opportunity  to  ])ractiee  intul)ation  on  a  living  subject. 

Niimher  of  Iniuhalions. — In  the  above  series  1  case  re(|uircd  four  intu- 
bations. Another  case  required  three  intubations.  The  majority  required 
but  one  intubation  to  effect  a  cure. 

Kind  of  Antitoxin  Used. — The  antitoxin  employed  at  the  Willard 
I'arker  is  made  at  the  laboratory  under  tlie  supervision  of  Dr.  Wm.  H.  Park, 
of  the  New  York  City  Department  of  Health. 

Method  of  Intubation  Eniploi/ed  at  tJie  Willard  Parl-er  Hospital. — The 
dorsal  method  of  intubation  is  the  one  advocated  by  Dr.  E.  G.  Bryant  and 
Dr.  Thos.  De  L.  r.urckha':ter  at  the  Willard  Parker.  The  advantage 
claimed  for  it  is  that  we  can  do  without  assistants,  which  in  an  emergency 
is  a  great  advantage.  1  have  used  this  method  and  agree  with  Bryant  that  it 
is  preferable  to  the  ujiright  position  advocated  by  O'Dwyer.  (See  Figs. 
184  to  187.) 

The  dorsal  position  in  intubation  is  also  used  and  advocated  by  Cassel- 
berry  of  Chicago ;   Carstens  of  Ix'ipsic  is  another  strong  advocate  of  it. 

Second  Series.  Children  Intubated  in  Private  Practice. — The  children 
of  this  series  Mere  seen  in  consultation  with  the  family  physician,  excepting 
1  case  (Case  11),  which  was  referred  to  me  for  personal  treatment.  They 
belong  to  the  better  class  of  children,  which  implies  better  sanitary  sur- 
roundings, better  food  and  j)r()m[)t  medical  aid  when  the  first  symptoms  of 
illness  are  noticed.  ]t  was  much  easier  to  study  this  series  of  cases,  as 
the  physician  in  attendance,  as  a  rule,  gave  me  the  required  data. 

Case  X  should  be  excluded  in  this  study,  as  the  child  coughed  up  its  tul)e 
(autoextubation)  and  died  of  asphyxia  before  the  physician  arrived.  Case 
IX  must  also  be  excluded,  as  it  was  im])ossible  to  obtain  satisfactory  details 
concerning  the  progress  of  Ihe  ease  aftei-  it  recovered  from  the  diphtheria. 

fl  cases  wci'o  intubated  8  years  ajjfo 

1  case  was  intubated  7  years  ago 
4  cases  were  intubated  5  j'ears  ago 

2  cases  were  intubated  4  years  ago 
2  cases  were  intubated  3  years  ago 
9  cases  were  intubated  2  years  ago 


INTUBATION.  603 

One  of  the  cases  in  this  series  contracted  scarlet  fever  and  died  two 
years  after  intubation.  So  that  3  cases  out  of  this  series  must  be  excluded, 
leaving  33  cases  from  which  reports  have  been  received. 

Day  of  the  Disease. 

1  case  was  intubated  on  the  1st  day  of  illness 
11  cases  were  intubated  on  the  2d     day  of  illness 

9  cases  were  intubated  on  the  3d  day  of  illness 
'2  cases  were  intubated  on  the  5th  day  of  illness 

Number  of  Ixtubatioxs  Required. 
15  cases  required  one      intubation 

2  cases  required  two     intubations 

3  cases  required  three  intubations 

1  case     required  four    intubations 

2  cases  required  five      intubations 

Length  of  Time  the  Tube  was  Worx. 
1  case     26  days  2  cases  7        days 

1  case     25  days  5  cases  6        days 

1  case     22  days  8  cases  5        days 

2  cases  14  days  1  case  4  V-  days 
2  cases  12  days 

The  average  length  of  time  the  tube  was  worn  in  the  above  23  cases  was 
yi/^  days  or  228  hours. 

Rachitis. — In  this  second  series  of  cases  we  are  dealing  with  children 
i)rought  up  in  excellent  surroundings.  In  the  families  of  the  better  class 
in  Xew  York  City  the  majority  of  mothers  do  not  nurse  their  own  infants. 
Wet-nurses  are  not  commonly  em.ployed.  Thus  tlie  larger  number  of  these 
children  are  to-day  brought  up  by  bottle  feeding.  It  is.  therefore,  no  wonder 
that  in  the  present  series  of  cases  rickets  due  to  malnutrition  or  inanition 
was  very  frequently  encountered.  The  susceptibility  of  the  rickety  child  has 
frequently  been  mentioned  by  many  authors.  In  this  second  series  of  cases 
rachitis  was  associated  in  19  cases. 

Condition  of  the  Throat. — Xot  one  of  these  cases  had  a  normal  throat 
at  the  time  of  the  intubation.  Adenoid  vegetations,  enlarged  tonsils,  and 
chronic  rhinopharyngitis  were  met  witli  in  almost  every  case.  When  the 
danger  of  a  diphtheritic  laryngeal  stenosis  in  a  child  is  considered,  then  it 
is  certainly  important  to  urge  the  removal  of  hypertrophied  tonsils  or 
adenoids  if  present,  and  to  restore  normal  conditions  in  the  rhinopharynx 
if  possible,  (ireater  attention  should  l)e  bestowed  on  the  nose,  as  the  most 
fatal  cases  are  those  of  nasal  diplitheria  in  which  general  sepsis  follows. 

After-effects  Resultinf)  from  Intubation. — Wliile  some  physicians  have 
reported  the  existence  of  a  bronchial  catarrh  during  the  first  and  second 
winter  months  following  intuljation,  the  majority  of  these  IG  cases  reported 


604 


THE   INFECTIOUS  DISEASES. 


absoluti'ly  iioriiial  conditions.  Two  cases  have  had  ])ncunionia,  in  one  child 
live  years  al'ter  intubation  and  in  tlie  other  child  three  years  after  intuba- 
tion. 

Ono  very  interesting  case  in  this  series  was  a  child  (an  idiot)  4  years  old,  seen 
in  consultation  with  Dr.  C.  Hoflfman.  This  was  one  of  tlie  most  trying  cases  and 
required  five  intubations  extending  over  a  series  of  twenty-five  days.  The  child  made 
a  splendid  recovery.  Such  cases  in  private  practice  m\ist  be  invariably  supervised 
by  a  trained  nui-se.  In  this  particular  ca.se  careful  feeding  in  addition  to  competent 
nursing  was  the  means  of  saving  tl\e  cliild's  life. 


Fig.   192. — Laryngeal  Diphtheria.     Child  4  years  o 
Seen  in  con.sultation  with  Dr.  C.  Hoffmann 


Id;   mentally  deficient. 
(Original.) 


Constant  cough  or  laryngitis  lasting  many  months  was  encounterpfl  in 
4  cases  of  my  series.  All  in  all,  there  is  no  case  in  my  series  in  which  a 
distinct  bronchial  or  laryngeal  catarrh  could  be  traced  to  or  associated  with 
the  intubation. 


INTUBATION.  g05 

Rogers  saj's:  "As  regards  the  etiology  of  postdiphtheritic  stenosis  of 
the  hirynx  and  retained  intubation  tubes,  the  views  of  the  hite  Dr.  O'Dwyer 
are,  of  course,  worthy  of  the  greatest  consideration.  iSTcvertheless,  I  believe 
they  are  wrong.  He  maintained  that  the  condition  was  the  fault  either  of 
the  operator  or  of  the  instruments,  which  means  careless  or  unskilled  inser- 
tion, or  the  use  of  poorly  constructed,  and,-  therefore,  improperly  titting 
tuljcs.  Formerly,  while  he  was  experimenting  with  and  perfecting  his  in- 
strument, he  sometimes  encountered  ulcerations  and  granulations;  and  the 
2  cases  he  reports  of  granulations  at  the  base  of  the  epiglottis,  where  it 
impinged  upon  the  head  of  the  tube,  might  properly  be  counted  in  this  class. 
At  all  events  there  is  no  other  record  of  a  similar  occurrence  from  the  use  of 
Uie  liard-ruhhcv  tube  as  at  present  made.  It  must  be  admitted,  however,  that 
erosions  and  ulcerations  are  possible  with  a  metal  tube,  as  its  surface  soon 
becomes  rough  from  a  deposit  of  what  is  apparently  calcareous  matter. 
But  whether  ulcerations  and  subsequent  cicatrices  may  not  be  thus  produced 
has  very  little  to  do  with  the  matter,  as  they  do  not  seem  to  be  the  usual 
cause  of  the  stenosis  in  the  reported  cases.  .  .  ,  And  it  is  important, 
from  a  medico-legal  aspect,  as  well  as  for  the  sake  of  intubation,  to  show  that 
neither  the  operator  nor  tube,  ordinarily,  has  anything  to  do  with  a  possible 
postdiphtheritic  stenosis.  It  is  granted  that  lacerations  and  serious  per- 
manent damage  to  the  larynx  can,  of  course,  be  inflicted  by  extreme  lack  of 
skill  or  care ;  but  to  claim  that  this  must  have  happened  in  all,  or  even  some, 
of  the  cases  of  retained  tube  is  not  borne  out  by  the  facts.  A  certain  amount 
of  traumatism  is  necessarily  inflicted  at  every  intubation,  and  if,  by  any 
chance,  a  chronic  stenosis  follows,  the  traumatism  is  always  blamed  for  it. 
That  this  is  wrong,  at  least  in  the  average  case,  is  proved  to  my  mind  by  the 
pathology  of  the  condition.  It  is  the  same  whether  the  stenosis  follows  intu- 
bation or  a  primary  tracheotomy." 

Causes  of  Becurring  Stenosis. — Emil  Kohl,  in  his  inaugural  address  at 
Zurich,  in  1884,  described  very  fully  the  pathological  condition  of  the 
larynx  in  cases  of  chronic  postdiphtheritic  stenosis  with  retained  tracheal 
cannula.  This  article  demonstrates  most  conclusively  that  not  the  least 
frequent  cause  of  the  difficulty  is  a  chronic  hypertrophic,  subglottic 
laryngitis,  a  chronic  thickening  of  the  soft  parts  between  the  vocal  cords  and 
the  lower  border  of  the  cricoid  cartilage.  The  hypertrophy  of  the  soft  tissue 
was  so  marked  ihat  respiration,  except  through  tracheal  fistula,  was  impos- 
sii)le.  These  cases,  of  course,  had  never  been  intubated;  and,  therefore, 
tlie  chronic  inflammation  within  the  larynx  cannot  be  charged  to  the  irrita- 
tion or  traunuitism  consequent  upon  the  insertion  or  wearing  of  an  intuba- 
tion tube. 

Another  and  more  frequent  cause  of  tfie  stenosis  was  sliown  to  be 
granulations  and  cicatrices  in  the  neighl)orhood  of  the  tracheal  wound  or 
cannula.    And  the  nearer  the  cannula  was  to  the  vocal  cords  the  worse  we^e 


GOG  THE  INFECTIOUS  DISEASES. 

these  complications.  The  vicinity  of  the  upper  end  of  the  wound  was  more 
prone  to  granulations  and  cicatrices  than  the  lower,  as  the  upper  end  gener- 
ally involved  or  was  close  to  the  larynx,  where  the  mucous  membrane  is 
more  loosely  attached  than  helow.  This  bears  upon  the  cause  of  the  stenosis 
described  in  some  of  tlie  reported  cases  of  retained  tul)es  which  have  finally 
been  tracheotomized.  If  the  tracheotomy  has  existed  long  enough,  it,  and 
not  the  original  intubation,  may  have  given  rise  to  the  cicatricial  tissue. 

Incidentally,  it  may  be  noted  that  the  number  of  devices  described  by 
Kijhl  for  remedying  a  postdiphtheritic  stenosis  will  illustrate  the  difficulties 
in  the  way  of  successful  treatment  other  than  by  intubation. 

Jn  speaking  of  the  operative  treatment  of  stenosis  of  the  larynx  follow- 
ing intubation  and  tracheotomy,  Arthur  R.  Duel  says:  "The  important 
points  to  remenibt'r:  (1)  About  1  per  cent,  of  all  patients  intubated  for 
acute  laryngeal  stenosis  will  'retain'  the  tube.  (2)  The  cause  of  the  reten- 
tion is  due,  in  the  majority  of  cases,  to  chronic  inflammation  of  the  intra- 
laryngeal  mucous  membrane  and  hypertrophy  of  the  subglottic  tissues,  and 
is  not,  as  has  been  generally  supposed,  the  result  of  granulation,  ulceration, 
or  cicatricial  bands.  (3)  Autoextubation  in  these  cases  is  the  rule,  and 
adds  greatly  to  the  danger  where  an  experienced  intubator  is  not  at  hand. 
Asa  result  of  this  a  large  number  of  such  cases  are  tracheotomized  for  safety. 
(1)  Where  high  tracheotomies  are  done,  cicatricial  "bands  are  almost  certain 
to  form  in  the  trachea  or  lower  part  of  the  larynx  above  the  tracheotomy 
wounds." 

The  points  in  treatment  which  should  be  emphasized  are:  (1)  The 
largest  sized  tube  possible  should  be  inserted,  under  an  anesthetic.  In  case 
of  contraction,  rapid  dilatation  should  be  done  by  beginning  with  the  small 
sizes  and  working  up  to  the  large  special  tube,  which  is  to  be  left  in  place. 
'J'his  special  tube  should  be  as  large  as  can  be  inserted,  and  the  constriction 
below  the  neck  only  V.n'  "ic-li  smaller  than  the  retaining  swell.  (3)  This 
tube  should  be  left  in,  undisturbed,  for  six  weeks  at  least.  It  should  then 
be  removed,  and,  if  a  cure  has  not  been  accomplished,  it  should  be  replaced 
for  six  weeks  longer. 

To  illustrate  the  above  the  following  case  may  be  cited : — 

Child  B.,  2  years  old,  was  seen  by  me  in  189.5,  in  consultation  Avith  Dr. 
McConville,  of  Brooklyn.  The  child  had  had  a  severe  pharyngeal,  tonsillar  and 
laryngeal  diphtheria.  The  temperature  was  101°  F.,  pulse  140,  respiration  labored. 
Child  cyanotic.  I  intubated  with  a  No.  2  metal  tube,  which  immediately  relieved 
the  laryngeal  stenosis.  The^general  condition  of  the  child  improved  greatly  and 
three  days  later  I  was  requested  to  extubate.  Several  minutes  after  extubation 
marked  laryngeal  stenosis  recuned  so  that  a  second  intubation  was  necessary.  The 
child's  condition  again  improved,  and  when  normal  conditions  prevailed,  in  about 
four  days  I  was  again  requested  to  extubate.  Thus  the  child  was  intubated  and 
extubated  every  four  days  for  a  month.  As  the  family  were  unable  to  retain  tho 
services  of  a  competent  trained  nurse,  and  as  the  child  required  frequent  medical 


INTUBATION.  607 

supervision,  the  case  was  transferred  to  the  Gouvemeur  Hospital.  Dr.  Rogers 
treated  tliis  ease  as  he  does  all  of  his  "retained  tube"  cases  by  introducing  the 
largest  sized  tube  that  can  be  wora,  and  allowing  the  tube  to  remain  in  situ  four, 
five  or  six  weeks  before  extubating.  After  one  month  of  this  treatment  I  was 
informed  that  extubation  permanently  relieved  the  condition  and  the  child  was  dis- 
charged from  the  hospital  cured. 

Parahjsis  of  the  Vocal  Cords. — Very  many  cases  have  been  reported  by 
competent  observers  on  both  sides  of  the  Atlantic.  In  America,  Waxham, 
Iioseuthal,  Engehnanu,  myself  and  many  others;  in  Europe,  von  Bokay, 
Trump,  Egidi,  Clalatti,  Massei,  and  Escat. 

Intubation  in  Hospital  Pmdice. — There  is  a  decided  difference  be- 
tween intubation  in  a  hospital  and  intubation  in  private  practice.  In  the 
Willard  Parker  Hospital,  Xew  York,  there  are  always  several  physicians 
ready  to  intubate  at  a  moment's  notice.  1  have  seen  more  than  one  case  of 
mild  stenosis,  treated  with  antitoxin  and  careful  dietary,  get  well  without 
intubation.  Haste  is  not  necessary,  and  each  case  is  carefully  treated. 
When  intubation  was  not  regarded  as  sufficient  relief  I  have  seen  several 
cases  tracheotomized  by  the  assistant  resident  physician.  Dr.  Beery,  with 
excellent  results. 

Intubation  in  Private  Practice  is  an  entirely  different  matter. 
Johann  von  Bokay  in  his  review  regarding  intubation  published  in  the 
"'Transactions  of  the  Section  on  Diseases  of  Children,"  held  at  Hamburg. 
1901,  honors  me  by  the  following  cpiotation^ :  "Auch  halte  ich"  das  Vorgehen 
von  Louis  Fischer,  des  hervorragenden  intubators  aus  Xew  York,  fiir 
unrichtig,  der  sagt:  Ich  maclie  es  m;r  zur  Eegel — wenn  ich  sicher  den 
Xachweis  liefern  kann,  dass  es  sich  urn  eihe  Diphtheric  handelt  und  ich  das 
A'orhandensein  des  Klebs-Loffler-Baci'lus  constatirt  habe,  die  intubation 
sofort  vorzunehmen,  wenn  sich  (Die  geringste  Stenose  zeigt." 

While  his  statement  is  partly  true,  it  does  require  a  slight  modification. 
When  a  mild  case  of  laryngeal  stenosis  is  encountered  in  private  practice, 
then  judgment  must  be  used  regarding  the  time  for  intubation.  The 
points  to  be  considered  are:  the  distance  at  which  the  patient  lives,  the 
amount  of  diphtheritic  infection  that  we  are  dealing  with,  and  the  circum- 
stances of  the  people  in  which  the  case  occurs.  If  the  child  is  fortunate 
enough  to  be  luider  the  observation  of  a  competent  nurse,  who  can  recognize 
the  slightest  increase  in  the  stenosis,  watches  the  condition  of  the  heart,  and 
calls  the  physician  the  moment  the  slightest  danger  arises,  then  the  condi- 
tions are  most  satisfactory  and  we  can  wait  with  intubation,  otherwise  we  are 
compelled  to  intubate  when  slight  evidences  of  stenosis  appear.  I  do  not  ad- 
vocate intuhation  the  moment  stenosis  exists.  In  Case  XXI  of  my  series  of 
private  cases  above  reported,  seen  in  consultation  witli  Dr.  I  Tarry  Weinstein, 


'  ]My  rule  is  to  intubate  when  the  slightest  stenosis  exists,  provided  the  clinical 
diagnosis  of  (liphtlicria   lias  been  vcrificil  by  the  ba<4criological  diagnosis. 


608  THE  INFECTIOUS  DISEASES. 

tlie  stenosis  of  the  larynx  ;vas  treated  by  an  injection  of  antitoxin,  the  child 
placed  under  the  care  of  a  c()iri[)rl(>nt  trained  nui'sc  with  detailed  instructions 
rcyurding  prjyressire  ay  in  plains.  Twelve  hours  laler,  when  the  stenosis  in- 
creased in  severity,  1  was  suuiuioned  hurriedly  to  intubate.  In  this  case  the 
child  wore  the  tube  six  days,  and  required  but  one  intubation  to  complete  the 
cure  of  the  stenosis.  In  America  the  nuijorlty  of  intubated  cases  occur  in 
private  practice.  Von  Bokay  states  that  accordiug  to  Jacobi,  only  5  per 
cent,  of  diphtheritic  laryngeal  stenosis  are  treated  in  the  special  (Willard 
Parker)  hospital.      The  rest,  95  per  cent.,  occur  in  private  practice. 

The  smooth  rubber  tube  with  or  without  metal  lining  is  now  generally 
used  for  the  relief  of  laryngeal  stenosis.  fSmootli  ruljber  tubes,  with  a  re- 
taining swell,  the  advantage  of  the  same  over  the  metal  tube  in  not  having 
calcareous  deposits  after  being  worn  for  weeks  is  certainly  noteworthy.  The 
corrugated  rubber  tubes  which  were  introduced  by  nie  several  years  ago  have 
certainly  served  me  very  well  in  many  cases  of  "retained  tube." 

The  following  case  occurred  in  llie  practice  of  Dr.  A.  W.  Newfield.  Tlie  child 
was  about  4  years  old,  and  had  sufl'ered  for  several  years  with  hypertrophied  tonsils 
and  ailenoid  vegetations,  in  addition  to  chronic  pharyngitis.  The  family  physician  ad- 
vised the  parents  to  have  the  throat  operated  owing  to  the  danger  of  infection  with 
diphtheria.  This  prophylactic  measure  was  not  carried  out.  I  saw  the  case  on  the 
second  day  of  illness,  in  consultation  with  Dr.  Newfield,  and  found  diphtheria  in- 
volving the  pharynx  and  tonsils  which  spread  very  rapidly  to  the  larynx.  The  same 
day  intubation  was  required  to  relieve  a  severe  stenosis.  The  stenosis  was  so 
severe  when  I  saw  the  child,  and  the  pulse  so  weak,  that  it  required  a  rapid  intro- 
duction of  the  tube  to  afford  relief.  An  injection  of  3000  iniits  of  antitoxin  was 
given.  Three  days  later  a  second  injection  of  3000  units  was  made;  so  that  6000 
units  were  injected  in  all.  There  was  recurring  stenosis  when  the  tube  was  re- 
moved. It  was  necessary  to  intubate  Within  ten  minutes.  Extubation  was  per- 
formed once  every  five  days?,  and  reintubation  was  necessary  a  few  minutes  to  one- 
half  hour  after  removing  the  tube.  Eubber  tubes  only  Avere  used  in  this  case.  After 
the  second  intubation  an  alum  gelatine  film  was  used  on  the  tube. 

After  the  third  intubation  it  was  deemed  necessary  to  use  a  corrugated  tube 
dipped  in  a  solution  of  hot  gelatine  containing  3  per  cent,  of  ichthyol  and  alum. 
This  tube  was  worn  about  five  days.  After  the  extubation  tlie  child  breathed  well 
for  about  one  hour  without  a  tube.  A  mild  form  of  stenosis  was  noticed  and  it 
was  deemed  safe  to  reintubate  with  an  ichthyol  alum  gelatine  film  on  a  No.  4  conni- 
gated  rubber  tube.  This  tube  remained  about  six  days  and  was  then  removed. 
Stenosis  did  not  recur  and  the  case  was  discharged  cured.  Later  on  the  adenoids 
•Jind  hypertrophied  tonsils  were  removed  and  the  child  has  been  well  since. 

Conclusion. — All  the  children  in  both  these  series  that  recovered  had 
been  breast-fed.  This  form  of  feeding  must  have  had  an  important  bearing 
on  their  bony  development  as  well  as  their  muscular  structure. 

.No  chronic  cough  which  could  be  attributed  to  the  w^earing  of  the  tube 
was  encountered.  It  was  presumed  by  me  at  the  outset  of  my  investigation, 
that  I  might  meet  with  a  series  of  cases  of  chronic  laryngitis,  chronic 
tracheitis  and  chronic  bronchitis,  dating  back  to  the  intubation.      We  know 


INTUBATION.  609 

that  pressure  of  the  tube  has  frequently  caused  decubitus;  hence,  it  is  pre- 
sumed that  an  inflammatory  jirocess  might  be  invited  from  the  wearing  of 
the  tube.  Comparing  an  equal  number  of  children  of  the  same  age  and 
development  who  never  suffered  with  diphtheria,  nor  were  intubated,  it  was 
found  that  they  suffered  with  pneumonia  and  other  infectious  diseases  in  the 
same  proportion  as  children  in  my  series  of  cases.  This  would  seem  to  be 
a  splendid  argument  in  favor  of  intubation,  as  it  shows  two  important 
points : — 

First. — The  tolerance  of  the  larynx  to  a  tube  for  many  weeks,  one  of 
my  cases  having  worn  a  tube  twenty-six  days,  another  case  twenty-five  days. 

Second. — That  a  properly  fitting  tube  constructed  of  rubber  leaves  no 
evidence  of  chronic  inflammation  directly  traceable  to  the  tube.  In  every 
one  of  my  cases  I  questioned  carefully  if  any  catarrh  originated  from,  or 
could  be  associated  with,  the  wearing  or  removal  of  the  tube,  and  received 
negative  replies. 

Equally  interesting  was  it  to  study  the  contour  of  the  thorax  and  to 
see  if  the  development  of  the  thorax  suffered  by  reason  of  these  children 
wearing  tubes. 

In  spite  of  the  fact  that  the  large  majority  in  the  first  scries  as  well  as 
in  the  second  were  decidedly  rachitic,  no  deformity  of  the  chest  due  to  imper- 
fect oxygenization  could  bo  attributed  to  the  effects  of  the  intubation  tube. 
An  etiological  factor  and  one  on  which  a  great  deal  of  stress  has  already 
been  laid,  is  that  90  per  cent,  in  my  first  series  of  cases  suffered  with  chronic 
throat  disease  in  some  form,  such  as  hypertrophied  tonsils,  chronic  pharyn- 
gitis, or  adenoids.    In  some  all  of  the  above  conditions  were  apparent. 

It  is  safe  to  presume  that  chronic  throat  disease  invites  infection,  and  I 
believe  that  there  is  a  direct  relationship  between  the  seed  and  the  soil.  If 
children's  throats  are  in  a  nornuil  condition,  then  the  risk  of  infection  is 
reduced  to  a  minimum.  It  is  our  duty,  therefore,  to  urge  all  mothers  to 
have  diseased  conditions  removed,  and  thus  try  to  prevent  the  infection  of 
diphtheria,  which  is  certainly  a  serious  condition. 

Recurrixg  Laryngeal  Stenosis  Following  Intubation 
AND  Decubitus. 

Etiology. — This  condition  is  primarily  caused  by  forcibly  pushing  a 
tube  into  an  oedematous  or  infiltrated  mucous  membrane.  O'Dwyer  says 
that  it  is  caused  ])y  using  a  tube  that  is  too  large  for  the  lumen  of  the 
larynx;  usually  in  the  hands  of  inexperienced  operators.  ]\Ietallic  tubes 
that  have  been  worn  for  a  long  time  contain  large  calcareous  deposits — the 
latter  are  due  to  a  deposit  of  lime  salts  contained  in  the  diphtheritic  mem- 
brane— and  when  removing  such  a  tube  during  extubation,  the  mucous  mem- 
brane is  easily  lacerated,  and  thus  ulceration  is  caused  thereby.  One  of  the 
most    important    papers    given    to    the    profession    was    read    by    the    late 


610  THE  INFECTIOUS  DISEASES. 

Josqili  O'Dwycr/  In  his  in\[)vr  entitled  "Retained  Intubrflion  Tubes"  he 
says:  "The  cause  of  2)ersistent  stenosis  i'ollowing-  intubation  in  hiryngeal 
diphtheria  can  be  summed  up  in  tlie  single  word  'traumatism.'  Paralysis 
of  the  vocal  cord  may  possibly  furnish  an  occasional  exception  to  this  rule." 

Thus  an  injury  to  the  larynx  can  be  done  by  a  tube  that  does  not  lit; 
it  may  result  from  an  imperfectly  constructed  tube,  or  from  a  perfect  tube 
that  is  too  large  for  the  lumen  of  the  larynx,  although  proper  for  the  age, 
or  from  a  tube  tbat  is  perfect  in  tit  and  make  if  not  cleaned  at  proper  inter- 
vals. OT)\vyer  states  that  the  seat  of  the  lesion  that  keeps  up  the  stenosis 
is  just  below  the  vocal  cords  in  the  sub-glottic  division  of  the  larynx,  or  that 
portion  of  tlie  organ  bounded  by  the  cricoid  cartilage.  Exceptions  to  this 
rule  result  from  injury  produced  by  the  head  of  the  tube  on  either  side  of 
the  base  of  the  epiglottis,  just  above  the  ventricular  bands.  The  reasons 
given  by  O'Dwyer  for  the  existence  of  the  stenosis  at  this  particular  portion 
can  best  be  explained  by  the  following : — 

Pathology. — Anatomicalh',  nornudly,  there  exists  a  constriction  in  the 
cricoid  region.  When  the  mucous  membrane  infiltrates  or  gets  oedematous 
it  swells  to  such  an  extent  and  only  toward  the  center,  as  the  outside  is  sur- 
rounded by  cricoid  cartilage;  and  while  swelling  toward  the  center,  me- 
chanically impedes  respiration  and  thus  calls  for  mechanical  relief,  i.e.,  intu- 
bation. O'Dwyer  states  that  if  a  tube  is  forced  into  the  larynx  in  a  case  of 
this  kind,  ulceration  and  sloughing  of  the  tissues  is  inevitable,  and  in  some 
instances  necrosis  of  the  cricoid  cartilage  can  result  from  interference  with 
the  circulation.  Our  only  safeguard  in  preventing  too  much  mechanical 
injury  as  in  the  condition  above  cited  is  to  introduce  "a  tube  of  small 
caliber." 

In  the  early  stage  of  this  form  of  cases  the  dyspnoea  returns  slowly; 
sometimes  several  days,  or  in  some  instances  only  a  few  hours,  may  pass 
before  the  former  condition  of  laryngeal  stenosis  is  recognized  and  the  neces- 
sity for  the  introduction  of  a  proper  tube  is  demanded. 

When  the  dyspnoea  returns  slowly,  it  means  that  the  lining  membrane 
of  the  larynx  cannot  swell  while  the  tulje  is  in  position  because  it  is  com- 
pressed between  the  tube  and  the  cartilage.  It  requires  some  time  for  the  re- 
appearance of  the  oedematous  tissue,  which  drops  into  the  chink  of  the 
glottis  and  obstructs  the  respiration,  the  latter  condition  being  mechanically 
prevented  as  long  as  the  tube  was  in  situ.  Exceptional  cases  have  been  re- 
ported where  granulation  tissue  springs  up  from  the  antero-lateral  aspects  of 
the  larynx  just  above  the  ventricular  bands.  O'Dwyer  states  that  the 
origin  of  this  growth  is  a  slight  ulceration  or  eros'on  of  the  mucous  mem- 
l)rane  at  the  ])oints  corresponding  to  the  greatest  transverse  diameter  of  the 
shoulder  of  the  tube  from  the  pressure  exerted  during  the  act  of  swallowing. 

Paralysis  of  Hip  Vocal  Cords,  although  known  to  exist,  is  very  hard  to 

*  American  Pediatric  Society,  at  Washington,  May  G,  1897. 


INTUBATION. 


611 


diagnosticate  without  a  proper  laryng-oseopic  examination.  Like  otlier 
forms  of  parahsis  it  comes  very  late  in  the  course  of  the  disease,  and  if,  after 
wearing  an  intubation  tube  for  a  short  time,  laryngeal  stenosis  recurs,  it  is 
safe  to  assume  that  paralysis  of  the  vocal  cords  is  not  the  cause  of  the  im- 
mediate recurring  stenosis.' 


Date.    1  1  1  2  1 

3     4     5     6     7     8 

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Fig.  19,3. — Case  seen  in  consultation  with  Dr.  S.  M.  Lansdmann.  Diph- 
theria. Larj-ngeal  stenosi.s  requiring  intubation.  Normal  conditions  and 
oxtuliation  on  the  fifth  day.  Two  days  later,  on  the  seventh  day  of  illness, 
a  sudden  high  fever,  due  to  over-feeding,  required  diet  and  calomel.  Case 
recovered.      (Original.) 

IIoiv  can  we  prevent  recurring  laryngeal  stenosis  in  ordinary  mem- 
branous diphtheria?  Every  tube  must  be  introduced  in  the  gentlest  manner 
possible,  the  slightest  force  exerted  will  lacerate  the  tissues.  It  is  a  wise 
rule  to  remove  the  tube  every  five  days;  according  to  O'Dwycr,  tubes  should 
be  removed  at  the  end  of  five  days  to  avoid  irritation  from  calcareous  de- 
posits. These  deposits  will  only  farm  on  inrlal  and  not  on  the  nihhcr  tubes. 
This  has  been  pointed  out  l)y  most  writers,  and  is  l)orne  out  by  experience. 


612  I'HE  INFECTIOUS  DISEASES. 

Treatment. — Intni-laryngeal  Mcdicalian :  \\\\vu  laryngeal  stenosis  re- 
curs and  it  is  necessary  to  intubate  several  times,  local  medication  of  tJie 
larynx  may  do  good.  This  is  especially  true  it  we  are  dealing  with  ulcer- 
ations caused  by  the  end  of  the  tube  during  deglutition.  Ulcerations  caused 
by  the  pressure  of  the  tube  are  the  ones  known  as  decubitus  ulcerations. 
They  most  frequently  result  from  irritations  caused  by  the  calcareous  de- 
posits on  the  metal  tubes.  Such  calcareous  deposits  produce  irritation  and 
finally  ulceration. 

O'Dwyer,  many  years  ago,  advocated  the  use  of  a  gelatine  film  contain- 
ing such  medications  as  ichthyol  or  alum.  The  writer  has  for  some  years 
past  used  with  a  varying  degree  of  success  certain  formulae  which  have 
served  him  quite  well  in  certain,  cases.  The  following  method  of  coating 
tubes  is  recommended :  For  a  child  2  years  old,  take  a  1  year  size  tube  and 
have  the  same  coated  with  the  following : — 

French  gelatine,  shredded 2.0 

Glycerine    2.0 

Water    ' 10.0 

Ichthyol    1.0 

Dissolve  over  a  water  bath  and  immerse  the  tube,  being  careful  not  to  close  the 
ends.  Place  the  tube  on  pins  stuck  through  a  piece  of  cardboard  and  allow  to  dry. 
Should  too  thick  a  layer  of  gelatine  have  been  acquired,  hold  near  the  spout  of  the 
water  bath  and  allow  the  steam  to  play  on  the  tube,  causing  the  excess  to  drip  off. 

If  we  have  fever  and  a  very  rapid  and  feeble  pulse,  and  the  general 
circulation  is  poor,  with  cold  extremities,  then  tonics,  such  as  iron  and 
strychnine,  or  restoratives,  such  as  codliver-oil  and  malt  extract,  should  be 
ordered  in  addition  to  concentrated  foods.  Thus  by  restoring  the  normal 
condition  and  by  assisting  the  nutrition  we  can  hope  for  the  repair  and  heal- 
ing of  superficial  lesions.  It  frequently  happens  that  in  spite  of  "a  medi- 
cated tube,"  such  as  above  described,  stenosis  will  recur.  In  order  to  guard 
against  possible  calamities,  it  is  wise  to  have  another  tube  with  its  proper 
medicated  gelatine  film  ready  to  be  used  if  occasion  requires  it.^ 

False  Passage. — Repeated  forcible  attempts  at  intubation  will  lacerate 
the  tissues.  It  is  not  infrequent  to  enter  the  ventricles  of  the  larynx,  pro- 
ducing a  false  passage  by  such  forcible  attempts  at  intubation.  If  a  false 
passage  has  been  produced,  then  laryngeal  stenosis  will  not  be  relieved,  and  it 
is  much  wiser,  if  an  expert  intubator  cannot  be  found,  to  immediately  resort 
to  tracheotomy.  The.  great  danger  of  collapse  due  to  heart  failure  must 
always  be  remembered,  hence  it  is  advisable  that  the  operation,  Ix'  it  intu- 
bation or  tracheotomy  should  be  done  quickly  thus  lessening  shock. 


1 


'A  comf)lete  paper  on  "Intubation  with  Clinical  Results  of  Intra-larvngeal  Med? 
cation"  was  published  by  me  in  Arcliivos  of  Pediatrics,  February,  1904. 


EXTUBATION. 


613 


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Fig.  194. — Temperature  Chart  from  a  Case  of  Laryngeal  Diphtheria. 
Excellent  Tlo.sult  of  Intubation  and  Antitoxin.  Doubtful  Trognobis.  Re- 
covery.     (Original.) 


EXTUBATI0^'■. 

How  to  Extubate. — First  step  in  the  operation  :  place  gag  in  position : 
locate  the  tul)e  with  the  left  index  finger;  guide  the  extractor  along  the 
finger  until  the  beak  enters  the  Inmen  of  the  tube.  Second  step  in  the  oper- 
ation: depress  the  handle  of  the  extractor  to  hold  tube  firmly,  and  with- 
draw the  tube  slowly.      (See  Figs.  186  and  187.) 

When  to  Extubate. — Five  days  is  a  fair  length  of  time  for  the  tube 
to  be  left  in  tho  lar^Tix.  The  following  rules  have  served  me  best  in  a 
very  large  experience  in  hospital  and  private  practice: — 

Let  the  child's  condition  be  the  guide  as  to  when  to  extubate.  My 
advice  is  to  leave  the  tulje  in  the  larynx  at  least  four  days,  then  remove  the 
same. 

The  question  to  1)0  considered  is,  can  the  child  undergo  the  shock  of 
extubation,  and,  if  need  be,  reintubatiou. 


614  THE  INFECTIOUS  DISEASES. 

If  the  temperature  is  over  100°  F.,  and  the  pulse-rate  is  small,  rapid, 
and  over  1"^0,  it  is  better  to  wait  with  the  extubation. 

A  rubber  tube  left  in  the  larynx  does  not  have  calcareous  deposits  as 
we  find  them  on  the  metal  tubes,  hence  there  is  uo  danger  in  leaving  a 
rubber  tube  in  situ  for  several  weeks. 

If  the  tube  is  plugged  with  mucus  or  membrane  it  may  be  necessary  to 
remove  the  tul^e  and  clean  it.  A  rattling  or  crowing  sound  in  addition  to 
laryngeal  stenosis  usually  indicates  this  condition. 

At  the  Willard  Parker  Hospital  there  is  no  definite  rule  as  to  the 
number  of  days  a  tube  remains  in  the  larynx.  Individual  conditions 
govern  the  time  of  extubation.  In  some  cases  tubes  are  removed  after 
forty-eight  hours.  The  severity  of  the  cases  admitted  to  the  hospital  and 
the  complication  must  be  taken  into  consideration.  Uncomplicated  cases 
may  be  extubated  any  time  between  the  third  and  seventh  days  when  the 
(jedema  of  the  larynx  subsides.  In  a  few  instances  the  child  expels  the  tube 
without  having  recurring  stenosis.  This  auto-extubation  is  occasionally 
seen;  it  is  Xature's  method  of  removing  a  foreign  body  after  the  subsidence 
of  the  inflammatory  condition. 

A  very  interesting  observation  recently  made  at  the  Willard  Parker 
Hospital  by  Dr.  William  Studdiford  is  that  a  child  with  otitis  does  not  do 
as  well  in  extubation  as  one  whose  ears  are  normal.  It  seems  quite  evident 
that  reflex  disturbance  caused  by  severe  pain  may  finally  result  in  spasm  of 
the  glottis.  A  good  point  therefore  is  to  have  the  ears  examined  before 
attempting  extubation. 

Antispasmodic  Treatment. — Before  resorting  to  extubation,  it  has  l)een 
my  rule  to  give  a  large  dose  of  bromide  of  sodium  combined  with  chloral  hy- 
drate at  least  six  hours  before  extubating.  At  the  Willard  Parker  Hospital, 
morphine  is  sometimes  used  hypodermically  in  doses  of  ^/^^  to  Vs  of  a  grain, 
depending  on  the  age  and  strength  of  the  child  to  be  extubated.  This 
method  is  very  successful,  especially  when  all  evidence  of  diphtheria  has 
passed,  and  it  is  simply  necessary  to  relieve  peripheral  irritation  to  avoid 
spasm. 

Choick  Between  Intubation  and  TR.\.cnEOTOMY. 

In  cases  where  operation  is  indicated  it  may  be  said  that  intubation  has 
steadily  grown  in  favor,  and  its  advantages,  when  it  is  indicated,  are  so 
obvious  as  to  recpiire  no  recapitulation  here.  On  the  other  hand,  conditions 
are  sometimes  present  that  render  intubation  impractical)le  or  inadmissible. 
or  at  least  render  tracheotomy  preferable.  It  is  therefore  desirable 
to  keep  clearly  in  mind  the  factors  that  determine  tlie  clioice  in  favor 
of  one  or  tlie  other  of  these  o])eratioiis.  Tliis  sul)j('ct  has  received  con- 
sideration in  a  study,  l)y  Drs.  CJeorge  Alsberg  and  Sigmund  Heimann,  of  the 
cases  of  diphtheria,  to  the  numl)er  of  403;],  observed  at  the  Kaiser  und 


TRACHEOTOMY.  615 

Kaiserin  Friedricli  Kinderkrankeuhaus,  iu  Berlin,  for  the  ten  3'eafs  from 
1891  to  lyOU.  As  a  result  of  this  analysis  it  is  concluded  that  operative  in- 
tervention in  cases  of  stenosis  of  the  larynx  of  slight  and  moderate  degree 
should  be  obviated  as  far  as  jjossible  by  means  of  antitoxin  and  the  employ- 
ment of  sprays.  Primary  intubation  is  indicated  in  all  eases  of  stenosis  of 
the  larynx  of  severe  degree,  in  which,  so  far  as  the  clinical  picture  makes  it 
appear  possible,  a  cutting  oj^eration  can  be  avoided.  Primary  tracheotomy 
is  indicated  in  the  presence  of  asj)liyxia  and  collapse,  of  pneumonia,  of  severe 
heart  disease,  of  jjarah'sis  of  the  j^ahite  and  diaphragm,  of  profound  anatomic 
changes  in  the  pharynx,  as  well  as  marked  tumefaction  of  the  entire  pharyn- 
geal structures  when  necrotic. 

Secondary  Tracheotomy  is  indicated  when  the  symptoms  of  stenosis 
persist  in  marked  degree  with  the  tube  in  place,  providing  its  lumen  is  not 
occluded,  when  pneumonia  supervenes,  and  when  paralysis  of  the  palate 
and  diaphragm  supervenes.  Intubation  is  not  recommended  in  nursing  in- 
fants by  some  writers  on  account  of  the  diminutiveness  of  the  parts  and  of 
the  narrow  lumen  of  the  pharynx,  but  especially  on  account  of  the  increased 
difficulty  in  feeding  from  the  presence  of  the  tube,  which  at  this  time  of 
life  is  of  vital  importance.  j\Iy  personal  experience  is  just  the  reverse,  and 
my  results  have  been  excellent.^ 

TKACIIEOTOilY   (Ix  AcUTE  OR  SUBACUTE  LaRYXGEAL  StEXOSIs). 

If  laryngeal  stenosis  persists  in  spite  of  intubation,  then  secondary 
tracheotomy  is  indicated.  When  extensive  oedema  of  the  larynx  exists,  in 
which  ease  intubation  fails  to  relieve,  tracheotomy  may  be  required.  I  have 
frequently  met  surgeons  who  were  well  posted  on  tracheotomy,  but  were  not 
familiar  with  the  delicate  modus  operandi  of  intubation. 

If  laryngeal  stenosis  threatens  life,  and  the  physician  is  not  acquainted 
with  the  method  of  intubation,  then  by  all  means  perform  tracheotomy, 
rather  than  risk  ''experimental  intubation." 

When  emergencies  arise  they  should  be  met  by  quick  action.  An  in- 
teresting case  of  suffocation  due  to  laryngeal  stenosis  was  told  to  me  by 
jny  friend,  Dr.  (xcorge  F.  Shrady : — 

A  child  suireiing  wiUi  croup  suddenly  collapsod  and  was  tliought  dead,  when 
Dr.  Shrady,  in  the  emergency,  took  a  razor  which  was  handy  and  made  an  incision 
into  the  trachea.  He  used  a  bent  hairpin  instead  of  a  tracheal  dilator.  The  child 
breathed  as  soon  as  oxygen  was  admitted.    Tlie  case  recovered. 

I  have  seen  cases  successfully  traclicotonii/cd  by  Dr.  Tiirone  and  Dr. 
?)cery,  and  have  also  assisted  Dr.  Burckhalter  in  performing  tracheotomy  at 


'  See  case  of  Baby  R.  in  tlie   practice  of  Dr.  Kahrs,   "Intubation  in  Private 
Practice." 


616  THE  INFECTIOUS  DISEASES. 

the  Wniard  Parker  Hospital,  when  intubation  did  not  relieve  laryngeal 
stenos^is — a?^  in  subglottic  eedenia. 

The  Operation. — Ana'}<t1ietic:  If  time  perniits,  a  few  drops  of  chloro- 
form should  bo  given.  If  septic  stupor  exists  then  no  ana?sthetic  should  be 
given. 

The  high  operation  "tracheotomie  superieure''  in  which  the  incision  is 
made  in  the  upper  portion  of  the  trachea  is  preferred  to  the  lower  operation 
advised  by  Trousseau,  known  as  "tracheotomie  inferieure." 

The  upper  portion  of  the  trachea  is  quite  superficial  and  it  is  best  to 
make  an  incision  exactly  in  the  median  line,  at  least  two  inches  in  length. 
It  is  important  to  remember  that  the  branches  of  the  inferior  thyroid  veins 
are  innnediately  nnder  the  place  chosen  for  the  operation,  hence  the  parts 
must  be  carefully  dissected  with  a  blunt  instrument,  such  as  the  back  of  a 
scalpel,  until  the  trachea  is  reached.  If  there  is  severe  bleeding  the  veins 
should  be  seized  with  a  forceps  unless  eiuergency  denumds  rapidity  of  action. 
The  dissection  should  be  continued  until  the  trachea  is  reached.     When  there 


I 


Fig.  195. — Silver  Trachea  Cannula 
used  in  tracheotomy. 


Fig.  196. — Hard  Rubber  Trachea  Cannula. 


is  considerable  oozing  of  blood,  and  our  view  is  thus  obstructed,  we  must 
remember  to  keep  in  the  center  of  the  throat,  which  invariably  brings  us  to 
the  rings  of  the  trachea.  By  placing  the  finger  in  the  wound  we 
will  feel  the  respiratory  mavement  of  the  trachea.  When  the  trachea  is 
reached  it  should  be  hooked  up  with  a  tenaculum  and  an  incision  made  large 
enough  to  admit  the  tracheotomy  tube.  The  rush  of  air,  so-called  tuhal 
sound,  characteristic  of  intubation,  is  also  heard  when  tracheotomy  is 
properly  performed. 

After-effects  of  ike  Traclieotoiny  Tube.— The  presence  of  the  tube  in 
the  trachea  invariably  excites  cough.  This  expels  loose  membranes 
and  other  viscid  accumulations.  High  fever  sometimes  follows  this 
operation,  although  as  a  rule  the  temperature  will  only  reach  101°  or 
102°  F. 

The  pulse-rate  should  be  carefully  observed;  a  gradually  increasing 
pulse-rate  during  the  first  three  days  after  the  operation  is  a  very  bad  sign. 

Complications.^Broncho-pneumonia  and  nephritis  are  to  be  feared,  for 


CHRONIC    DIPHTHERIA.  617 

they  frequently  terminate  fatally.      The  treatment  of  complications  is  the 
same  as  though  the  disease  existed  independent  of  the  operation. 

After-treatment. — Careful  aseptic  niethods  must  be  the  rule  from  the 
moment  the  child's  stenosis  is  relieved.  The  infection  of  the  wound  will 
always  be  an  added  source  of  danger.  As  the  majority  of  cases  of  trache- 
otomy will  be  performed  for  extensive  pseudomembranous  stenosis,  we  must 
remember  that  septic  diphtheria  ijer  se  may  cause  death  independent  of  the 
added  danger  incident  to  the  opening  of  the  trachea.  All  oozing  of  blood 
must  be  checked ;  pressure  with  sterile  gauze  saturated  with  MonselFs  solu- 
tion has  served  me  well.  I  have  also  used  gauze  dusted  with  a  powder  con- 
sisting of: — 

IJ  Europhen     7  parts 

Alum  3  parts 

To  Check  Ilcemorrhage. — The  local  application  of  adrenalin  solution, 
1  to  5000,  is  very  valuable  during  the  operation. 

The  internal  cannula  shoiild  be  removed  and  cleaned  every  two  or  three 
hours,  Aviped  dry  and  replaced.  In  rare  instances  it  may  be  necessary  to 
cleanse  the  cannula  less  frequently.  This  can  best  be  determined  by 
watching  the  respirations  and  instructing  the  trained  nurse  as  to  when  the 
caliber  of  the  tube  requires  cleansing.  Noisy,  rattling  sounds  due  to  the 
presence  of  mucus  in  the  tube  do  not  necessarily  mean  that  the  cleansing  of 
the  cannula  is  urgent,  if  the  child  is  quiet  or  asleep.  If  the  child  is  restless 
and  turns  its  head  from  side  to  side,  and  usually  mucus  rattling  is  heard  in 
addition,  then  it  is  an  indication  for  cleansing  the  tube. 

Cleansing  the  ^Vound. — Each  day  following  a  tracheotomy,  it  is  advisa- 
ble to  place  the  child  on  the  operating  table,  withdraw  the  tracheotomy  tube 
and  replace  it  with  a  new  one. 

A  writer  states  that  "after  the  second  or  third  removal  the  larynx 
should  be  examined  to  see  if  it  is  free  and  there  is  no  further  use  for  the 
cannula.^'  ]\Iy  experience  with  tracheotomized  cases  has  not  been  as  good  as 
tliat,  for  rarely  have  I  seen  a  tracheal  cannula  that  could  be  dispensed  with, 
although  antitoxin  was  administered,  in  less  than  seven  to  twenty-one  days. 
The  severity  of  my  cases  may  account  for  the  difference  in  experience.  At 
times,  in  spite  of  the  greatest  amount  of  care,  even  in  the  hands  of  experi- 
enced operators,  cicatrices  of  the  trachea  resulting  in  permanent  contraction 
or  exuberant  granulations  at  the  site  of  incision  will  require  the  continued 
use  of  the  tracheotomy  tube,  as  in  cases  described  in  the  chapter  on  "Intuba- 
tion," known  as  "retained  tube  cases." 

riiRoxrc  Dii'ii'iiiinuA. 
Tliere  are  two  varieties  which  characterize  this  condition. 
The   first   form   is   simply   the   continuation   of   an    acute    attack   of 
diphtheria,  running  a  prolonged  course.      Second,  a  chronic  form  in  which 


gl8  THE  INFECTIOUS  DISEASES. 

symptoms  of  pseudo-membranous  rhinitis  exist  and  which  may  be  present 
months  or  years. 

In  the  prolonged  type  previously  mentioned,  fever,  glandular  swelling 
and  general  systemic  disturbances  mark  the  beginning  of  the  attack.  In 
the  latter  type  the  febrile  manifestations  and  general  constitutional  dis- 
turbances are  totally  absent. 

Diagnosis. — The  clinical  picture  of  the  chronic  type  of  diphtheria 
narrows  down  to  two  distinct  features.  First,  the  presence  of  pseudo-mem- 
branes in  the  nose,  pharynx,  or  larynx,  for  months  or  years.  Second,  the 
persistence  of  the  Klebs-Loeffler  bacillus.  Third,  the  marked  absence  of 
general  constitutional  disturbances. 

Xeisser,  v.  Behring,  Walb,  and  more  recently  Newfield,^  describe  this 
form  of  diphtheria.  He  found  that  a  series  of  cases  of  rhinitis  atrophicans 
and  ozsena  showed  Klebs-Loeffler  bacillus  in  addition  to  the  ozgena  bacillus. 
1  have  met  with  cases  of  this  prolonged  type  of  diphtheria  which  clinically 
resembled  syphilis. 

Prognosis  and  Course. — Suclr  cases  require  very  careful  observation  and 
a  very  guarded  opinion  should  be  expressed  as  to  the  length  of  time  that 
the  condition  A\-ill  last.  Not  infrequently  tuberculosis  or  some  form  of 
chronic  broncho-pneumonia  may  follow  with  fatal  result.  In  a  case  of 
chronic  diphtheria  extending  over  seven  months,  which  was  complicated 
by  entero-colitis  during  midsummer,  the  result  was  fatal. 

Isolation. — The  presence  of  the  Klebs-Loeffler  bacillus  demands  the 
strictest  isolation  from  all  healthy  persons.  The  virulent  nature  of  the 
lioeffler  bacillus  should  be  remembered.  All  children  suffering  with  en- 
larged tonsils  or  those  having  adenoid  vegetations  should  be  carefully 
guarded  against  exposure  to  a  case  of  tliis  kind,  as  they  are  more  prone 
to  infection  than  those  having  healthy  throats. 

Treatment. — If  we  are  dealing  with  a  subnormal  condition,  the  system 
must  be  built  up  with  codliver-oil  in  addition  to  a  concentrated  diet,  such  as 
eggs,  cerea's,  and  broths.  The  most  valuable  drug,  undoubtedly,  is  iron. 
The  tincture  of  the  chloride  of  iron,  10  to  30  drops,  three  times  a  day,  or 
oftener,  is  very  useful  for  its  local  as  well  as  its  systemic  effect.  I  administer 
iron  regardless  of  its  constipating  tendency,  for  weeks  and  months. 

Locally,  a  bichloride  spray  or  a  spray  of  Dobell's  solution  can  be  used 
three  or  four  times  a  day.  If  after  several  weeks  of  persistent  treatment 
no  benefit  results,  then  a  decided  change  of  air,  such  as  a  trip  to  the  seashore 
or  to  the  mountains,  will  assist  in  the  cure  of  the  patient. 

DlI'irTIIEKOID. 

This  term  we  owe  primarily  to  the  French.  It  was  introduced  into  the 
German  literature  Ijy   Professor  Baginsky,  and  after  him,  by   Escherich. 


» D.  Med.  Woch.,  May  12,  1904. 


PSEUDO-DIPHTHERIA.  619 

This  disease  is  caused  by  an  infection  resulting  from  a  series  of  germs, 
chiefly  streptococci  or  staphylococci.  It  is  a  disease  which  differs  entirely 
from  diphtheria.  It  is  not  a  serious  disease.  There  are  no  Klebs-Loeffler 
bacilli  present.  The  usual  evidences  of  systemic  infection  are  absent.  The 
child  shows  the  clinical  evidences  of  an  infection  in  a  milder  form  than  is 
usually  met  with  in  diphtheria.  The  prognosis  is  good.  The  treatment 
should  be  directed  toward  restoring  the  normal  condition  of  the  body,  and 
hence  the  saccharated  carbonate  of  iron  given  in  5  to  10-grain  doses,  three 
or  four  times  a  day,  is  very  useful.  Locally,  an  astringent  antiseptic  gargle, 
consisting  of  equal  parts  of  DobelFs  solution  and  of  warm  water,  to  be  used 
every  hour  for  gargling,  or  a  1  to  5000  bichloride  of  mercury  solution  is 
very  useful.     Normal  salt  solution  is  also  recommended. 

The  nutrition  of  the  body  will  be  the  means  of  restoring  the  functions 
to  their  normal  state.  It  is  important,  therefqre,  to  feed  in  regular  inter- 
vals, milk,  soup,  broth,  and  eggs,  if  they  can  be  assimilated.  If  the  child 
is  a  bottle  baby  or  a  nursling  at  the  breast,  then  a  smaller  quantity  of  food 
should  be  given,  and  if  the  same  is  not  taken  by  the  mouth  then  rectal  ali- 
mentation will  be  urgently  called  for.  It  is  wise  to  isolate  each  and  every 
form  of  diphtheroid  affection  and  thus  prevent  the  possibility  of  the  trans- 
mission of  this  infection. 

PsEUDO  OR  False  Diphtheria. 

Under  this  general  title  are  included  all  cases  of  pseudo-membranous 
or  exudative  inflanmiation  of  the  mucous  membranes  in  which  the  diph- 
theria bacilli  are  absent. 

Since  Loeffler,  in  1889,  first  described  a  class  of  pseudo-membranous 
inflammations  of  the  throat  in  which  the  diphtheria  bacilli  were  absent 
and  cocci,  present,  it  has  been  established  that  a  certain  portion  of  the 
inflammations  of  the  respiratory  mucous  membranes,  which  closely  re- 
\  semble  the  less  characteristic  cases  of  diphtheria,  are  not  due  to  the  diph- 
theria bacilli,  but  to  cocci,  especially  to  streptococci. 

It  has  been  found  that  streptococci  are  commonly  present  in  the  throats 
of  healthy  persons,  or  at  least  in  the  throats  of  persons  living  in  large  cities, 
and  that  other  forms  of  cocci,  especially  the  pneumococci  and  staphylococci, 
are  apt  to  be  associated  with  them. 

These  germs  seem  to  live  in  the  thi'oat  without  creating  any  disturb- 
ance th(>re,  so  long  as  the  mucous  membranes  are  healthy;  but  under  cer- 
tain conditions,  as  when  the  mucous  membrane  has  been  made  vulnerable 
bv  e.\])osur('  to  cold  or  otlier  dclcicrious  inllncnces,  or  l)y  the  poison  of  scar- 
let fever,  measles,  or  some  other  disease,  the  streptococci,  alon(\  or  asso- 
ciated witli  other  cocci,  are  able  to  attack  the  raucous  membrane  and  to 
cause  an  iiidamuiation.  1'his  may  be  of  any  degree  of  intensity,  IVoiu  a 
I     simple    inilammatory    hypera'Uiia    to    an    infiannnation    with    an    extensive 


620  THE  INFECTJOIS  DISEASES. 

production  of  pseudo-uicmbrane  or  with  ulceration.  Such  infiannnations 
when  associated  with  the  formation  of  pseudo-membrane  are  known  as 
pseudo-diphtheria.  The  exudate  or  pseudo-membrane  in  pseudo-diphtheria 
is  usually  confined  to  the  tonsils,  but  other  parts,  such  as  the  larynx, 
pharynx,  and  nostrils,  nuiy  be  invaded. 

It  has  been  found  that  the  percentage  of  mortality  in  these  cases  is  far 
less  than  in  diphtheria,  and  that  the  disease  is  seldom,  if  ever,  commu- 
nicated to  others. 

Age  and  Mortality  in  False  or  Pseudo-diphtheria. — To  compare  the 
mortality  and  the  communicability  of  false  diphtheria  with  that  of  true 
diphtheria,  450  cases  of  the  false  were  carefully  investigated  by  sanitary 
inspectors  detailed  for  this  work.^  These  cases  comprised  300  occurring 
in  the  fall  months,  and  150  occurring  in  the  following  spring.  The  cases 
were  taken  in  consecutive  order,  and  are  Ijelieved   to  be  average  cases. 

In  the  450  cases  investigated  there  were  11  deaths,  or  about  2  V^,  per 
cent,  mortality.  Of  the  450  cases,  42  were  complicated  with  scarlet  fever, 
and  of  these  42,  4  died.  In  G  of  the  450  cases,  measles  occurred  as  a  com- 
plication, and  these  all  recovered.  Of  the  2  deaths  which  occurred  among 
the  adults,  1  was  of  a  man  of  70  years,  ^vho  was  suffering  from  a  serious 
valvular  lesion  of  the  heart,  and  the  other  was  a  young  adult  female,  who 
died  of  septica^nia. 

The  statistics  gathered  of  the  location  of  the  disease  in  the  true  and 
false  cases  are  of  special  interest.  There  were  286  of  the  cases  examined 
in  which  the  disease  was  entirely  or  chiefly  confined  to  the  larynx  or  bronchi, 
and  of  these  283  were  in  children.  In  the  cultures  of  229  of  the 
28G  characteristic  Loeffler  bacilli  were  found,  and  the  cases  were  thus 
proven  to  be  true  diphtheria.  Of  the  229  cases  in  which  the  Loeffler  bacilli 
were  found,  127  showed  no  jjseudo-membrane  or  exudate  above  larynx, 
while  in  the  remaining  ()2,  although  the  larynx  was  mainly  involved,  there 
was  also  some  membrane  or  exudate  present  on  the  tonsils  or  in  the  pharynx. 
In  5T  out  of  the  28()  examined,  no  diphtheria  bacilli  were  found,  but  in  17 
of  these  the  cultures  were  unsatisfactory.  Excluding  the  17  doubtful 
cases,  there  were  40  cases  of  pseudo-diplitheria  in  which  the  diphtheria 
bacilli  were  certainly  al)sent.  The  disease  was  confined  to  the  larynx  or 
bronchi  in  27  out  of  -40,  while  more  or  less  exudate  or  membrane  was 
present  on  tlie  tonsils  or  in  the  ])harynx  in  13. 

The  Proportion  of  Cases  of  Suspected  Diphtheria  which  upon  Exami- 
nation Prove  to  be  True  Diphtheria. — "As  soon  as  careful  investigation 
had  demonstrated  it  was  ))Ossible,  with  proper  precautions,  to  separate  by 
bacteriological  examination  the  cases  of  the  true  from  those  of  the  false 
diphtheria,  large  numbers  of  cases  suspected  to  be  diphtheria  were  exam- 


'  Bulletin  of  the  New  York  Health  Department. 


PSEUDO-UIPHTHERIA.  621 

ined  bactoriologically.  The  rej)orts  from  hospitals  in  which  all  cases  of 
suspected  diphtheria  were  examined,  are  of  special  interest  as  showing  the 
proportion  of  cases  of  true  to  false  diphtheria.  The  results  from  these  hos- 
pitals are  all  the  more  valuable  because  they  come  from  all  parts  of  the 
various  cities  in  which  the  respective  hospitals  were  located,  and  hence 
special  local  conditions  were  not  likely  to  greatly  influence  the  result  ob- 
tained. Thus,  Baginsky,  in  Berlin,  found  the  diphtheria  bacilli  in  120 
out  of  244  suspected  cases;  Martin,  in  Paris,  126  out  of  200;  Park,  in 
Xew  York,  127  out  of  244;  Janson,  in  Switzerland,  in  63  out  of  100,  and 
Morse,  in  Boston,  in  239  out  of  400.  Thus,  from  20  to  50  per  cent,  of  the 
cases  sent  to  diphtheria  hospitals  did  not  have  diphtheria. 

"If  we  examine  the  reports  of  examinations  made  under  some  special 
conditions,  as  during  an  outbreak  of  some  contagious  disease  in  a  hospital 
for  children,  we  find  the  results  may  differ  in  a  striking  manner. 

"Thus,  in  1889,  Prudden  made  bacteriological  examinations  of  24 
fatal  cases  of  pseudo-membranous  inflammation  of  the  tonsils,  pharynx,  and 
larynx.  In  none  of  these  were  the  Loeffler  bacilli  found  to  be  present. 
These  cases  occurred  in  two  hospitals  for  children  in  Xew  York  in  which 
both  scarlet  fever  and  measles  were  at  the  time  prevalent.  During  the  past 
year  we  have  examined  the  exudate  from  46  fatal  cases  of  suspected  diph- 
theria occurring  in  these  same  institutions,  and  found  the  bacilli  present  in 
44  of  them." 

If  scarlet  fever  and  measles  (but  not  true  diphtheria)  were  prevailing 
in  an  institution,  it  is  evident  the  bacilli  would  be  absent  from  the  pseudo- 
membranes  occasionally  occurring  in  the  throat  as  a  complication  of  these 
diseases. 

The  Mortality  in  True  Diphtheria  and  in  Pseudo-diphtheria.  —  All 
observers  have  found  the  mortality  far  higher  in  those  cases  in  which  the 
diphtheria  bacilli  were  present  than  in  those  in  which  they  were  absent.  In 
true  diphtheria  the  mortality  has  been  found  to  vary  from  25  to  70  per 
cent.,  while  in  pseudo-diphtheria  it  varies  from  0  per  cent,  to  20  per  cent. 

The  death  rate  in  cases  of  pseudo-diphtheria  occurring  in  hospitals 
averages  far  higher  than  the  death  rate  outside  of  such  institutions.  The 
reason  for  this  is  chiefly  to  be  found  in  the  fact  that  it  is  mainly  the  graver 
cases,  especially  those  suffering  from  laryngeal  obstruction,  which  are  re- 
moved to  the  hospitals. 


CHAPTKK   \ir. 

RUBELLA    (ROTHELN,    GERMAN    MEASLES,  FALSl^    ilEASLES). 

Ei'BHLLA  is  an  exantlieiiintous  eruption  sinnilating  measles.  Corlctl's 
description  of  nilx'lla  is  so  classic  that  I  give  it  word  for  word.^ 

"Iiubella  is  a  mild  form  of  infection  which  always  follows  a  benignant 
course  and  first  appears  as  a  general  or  eonstitutional  disease,  accompanied 
1)V  a  slight  rise  of  temperature  and  slight  feeling  of  illness.  In  this  it 
conforms  to  the  other  affections  of  this  class. 

"The  local  manifestations,  while  partaking  of  the  character  of  those 
observed  in  l)oth  scarlet  fever  and  measles,  are  distinct,  and  possess  an 
individuality  which,  as  a  rule,  may  be  recognized  by  the  trained  eye. 

''Etiology. — While  we  have  no  exact  knowledge  of  the  cause  of  the 
disease  and  in  what  respect  the  virus  differs  from  that  of  other  diseases  to 
which  it  bears  the  closest  resemblance,  yet  we  do  know  that  it  is  contagious, 
and  always  gives  rise  to  a  like  disease :   in  short,  conforms  to  the  type. 

"It  occurs  but  once  in  the  individual,  from  which  we  infer  that  it  is 
self -protective,  while  it  affords  no  protection  to  or  modification  of  measles 
or  scarlatina ;  nor  has  it  appeared  that  they  offer  any  protection  against 
rubella.  It  must  be  remembered,  moreover,  that  even  mild  forms  of  the 
various  exanthemata  are  self-protective.  The  fact  that  the  patient  has  had 
at  some  previous  time  either  scarlet  fever  or  measles,  or  both  of  these 
affections  in  a  well  marked  degree,  often  leads  to  its  recognition.  Some- 
times, even  before  its  true  nature  has  been  definitely  settled  in  the  mind 
of  the  medical  attendant,  the  disease  disappears. 

"Like  the  other  exanthemata,  it  always  appears  in  the  form  of  an 
epidemic,  which  seems  to  bear  little  or  no  relation  to  epidemics  of  other 
diseases,  such  as  scarlet  fever  or  measles." 

Bacteriology  and  Pathology. — Owing  to  the  mild  character  of  the  dis- 
ease, the  pathological  changes  have  not  been  studied.  There  are  certain 
changes  seen  in  the  skin,  described  by  Thomas.  Nothing  definite,  however, 
can  be  stated.  Bacteria  in  the  blood  of  children  suffering  with  rubella  have 
been  described  by  several  authors;  these  are  by  no  means  pathognomonic 
of  this  condition. 

"It  sometimes  occurs  independently ;  again,  two  or  more  of  the  epi- 
demic exanthemata  prevail  at  the  same  time.     It  must  be  admitted  that  ex- 


'  For  a  very  mimitp  doscriptinn  of  tliis  disease  the  reader  is  referred  to  Corlett's 
'Treatise  on  the  Acute  Exantliemata.'     Published  by  F.  A.  Davis  Company. 

(622) 


RUBELLA.  623 

traneoiis  conditions  of  weather  and  possil)ly  of  sanitation  predispose  in  a 
like  degree  to  all.  Though  epideniies  of  rubella  seem  to  oeeur  at  less  fre- 
(juent  intervals  than  do  those  of  either  scarlatina  or  measles,  there  can  be  no 
doubt  that  very  nuniy  epideuiics  of  rubella  escape  recognition,  and  are  re- 
garded as  mild  or  aberrant  forms  of  one  or  the  other  of  the  first  named 
affections.  AYhile  the  author  believes,  with  Atkinson,  that  unless  more 
exact  methods  are  adopted  in  the  study  of  the  exanthemata  there  is  still 
danger  of  endless  confusion,  and  that  the  practice  of  relegating  all  mild  or 
otherwise  anomalous  forms  of  measles  or  scarlatina  to  rubella  is,  as  it  was 
thirteen  A'ears  ago,  far  too  prevalent;  yet  the  remedy  lies  in  giving  to  this 
important  group  of  affections  a  more  conspicuous  position  than  it  now  holds 
in  the  curriculum  of  clinical  instruction." 

The  period  of  incubaiion  is  usually  from  fifteen  to  eighteen  days. 

Symptoms  and  Diagnosis. — The  symptoms  may  be  so  mild  that  they 
are  frequently  overlooked.  The  prodromal  symptoms  appear  a  few  hours 
before  the  rash  is  seen.  Some  authors  state  that  in  the  majority  of  cases 
they  are  wholly  absent.  I  have  frequently  seen  catarrhal  symptoms  such 
as  coryza  in  addition  to  suffusion  of  the  eyes,  on  the  day  previous  to  the 
eruption. 

Throat  syntptonis,  such  as  congestion  and  swelling  of  the  tonsils  and 
fauces,  are  usually  seen.  Cough  and  hoarseness  may  also  be  present.  The 
buccal  mucous  membrane  does  not  have  an  enanthem.  Forchheimer^ 
describes  what  he  considers  a  characteristic  enanthem  in  rubella  which 
appears  simultaneously  with  the  exanthem  and  remains  from  12  to  14 
hours.  Its  favorite  location  is  on  the  soft  palate,  sometimes  extending  to 
the  hard  palate.  It  consists  of  small  discrete  dark  red  but  not  dusky  papules, 
which  soon  disappear,  leaving  no  trace  behind.  The  rest  of  the  mouth 
may  or  may  not  be  congested. 

Sometimes  there  is  anorexia  and  occasionally  nausea  or  vomiting.  J. 
Lewis  Smith  describes  convulsions  seen  in  the  disease.  The  temperature 
varies  between  100°  and  101°  F.,  rarely  higher.  The  tongue  is  not  as 
thickly  coated  as  in  measles,  although  the  papilla  may  be  enlarged.  These 
projecting  papillae  appear  on  the  tip  of  the  tongue.  The  characteristic 
strawberry  tongue  is  absent. 

Sneezing  may  be  present  and  coryza  may  be  absent,  or  vice  versa. 

Thiorfelder^  states  that  "swelling  of  the  subauricularand  superior  jugu- 
lar lymphatic  glands  may  be  looked  upon  as  a  constant  prodromal  symptom." 
Atkinson^  says  "enlargement  of  the  superficial  lymphatic  glands  of  the  neck 
may  be  the  most  striking  symptom,  and  sonietimes  attracts  attention  several 
days  before  the  beginning  of  the  eruj)tion." 


"•"Gorman  Measles,"  Twontictli  ('cnlinv  Practice  of  Medicine,  New  York,  1808. 
^Tliiorfoldor:     Oreifsw.  Mc<l.  Hciti.,  B.  ii,  Ber.,  p.  14,  18G4. 
*  Atkinson  (loc.  cit.,  p.  23). 


024  THE  INFECTIOUS  DISEASES. 

Corlctt^  says  "his  cases  s1k)w  adenopathy  in  9G  per  cent.,  of  which  the 
niaxilhiry  and  superficial  or  post-cervical  were  the  most  frequently  in- 
volved; next  the  occipital,  posterior  and  anterior  auricular;  and  sometimes 
the  superficial  ini;uinal,  axillary,  and  the  epitrochlear.  In  the  neck  the 
inflannnation  may  be  sufficiently  severe  to  interfere  with  free  movement,  and 
in  two  or  three  instances  it  has  given  rise  to  marked  oedema  of  the  sur- 
rounding parts."  Suppuration  of  the  glands  is  never  observed.  The 
lymphatic  ganglia  are  also  involved  in  the  regicms  affected.  'J'he  spleen  is 
seldom  involved. 

Pauline  M.,  6  years  old,  was  brought  to  my  office  in  an  apparently  good  con- 
dition. I  was  told  that  the  child  had  a  rash  on  her  chest  and  back,  and  that  the 
temperature  was  100°  F.  in  the  rectum.  There  was  sneezing,  but  no  cough  nor 
broncliial  symptoms.  There  was  an  enlargement  of  the  glands  on  both  sides  of  the 
neck  along  tlie  posterior  border  of  the  sterno-mastoid  muscle.  The  buccal  mucous 
membrane,  pharynx,  and  tonsils  were  but  slightly  inflamed.  The  conjunctivae  were 
of  a  deep  pink  color.  Tlie  rash  was  scattered  over  the  abdomen  and  chest  and  was 
crescentic  in  its  arrangement,  similar  to  that  seen  in  measles.  The  highest  tempera- 
ture reached  was  101°  F..  in  the  evening,  pulse  was  100,  and  the  respiration  24.  The 
treatment  consisted  in  giving  a  mild  lauxative  and  liquid  diet.  Strict  isolation  was 
insisted  upon.  The  eruption  remained  about  three  days.  The  child  recovered 
without  any  complication. 

The  Eruption. — The  rash  is  first  seen  on  the  face  and  scalp.  It  is 
described  as  "faint  pinkish  macular,  at  first  discrete,  but  sometimes  becoming 
more  or  less  confluent  within  a  few  hours."  The  eruption  spreads  down- 
ward to  the  neck  and  upper  part  of  the  abdomen  until  the  upper  and,  lower 
extremities  are  covered.  The  palms  and  soles  are  usually  associated  in  this 
general  eruption.  The  eruption  reaches  its  full  development  after  one  or  two 
days.  It  spreads  slowly  and  fades  on  the  face  when  it  is  about  reaching  its 
height  on  the  lower  extremities.  Ilardaway  believes  that  this  dissimilarity 
in  the  appearance  of  the  eruption  is  a  valuable  means  of  distinguishing  ru- 
bella from  measles.  "The  individual  lesions  are  sometimes  perceptibly  ele- 
vated and  vary  in  size  from  a  pin-head  to  a  small  bean."  They  are  often 
slightly  elongated  or  irregularly  round  in  shape,  with  an  ill-defined  border, 
and  disappear  completely  on  pressure.  Unlike  measles,  they  show  no 
tendency  to  form  grou])s,  clusters,  or  crescents,  and  in  some  cases  manifest 
a  feebler  predilection  to  coalesce.  Sometimes,  however,  when  confluent  they 
extend  at  the  periphery,  coalesce,  and  form  extensive  areas,  when  the  re- 
semblance to  scarlatina  may  lead  to  an  error  in  diagnosis. 

"Usually  the  plaques  thus  formed  are  found  only  on  certain  parts,  while 
on  the  remaining  ])orti()ns  of  the  l)ody  the  eruption  presents  the  more  usual 
appearance.      'Hie  color  is   always   lighter  than   that  observed   in  scarlet 


^  Corlett,  "A  Treatise  on  the  Acute  Infectious  Exanthemata,"  p.  3.56. 


RUBELLA. 


625 


fever,  and  in  a  strong  light  the  slight  elevations  which  correspond  to  the 
original  lesions  may  be  discerned.  Further,  the  eruption  is  fairly  uniform 
in  color  and  may  be  described  as  of  a  faded  rose,  or  pink  tint,  never,  in  my 
experience,  presenting  the  fiery  red  of  scarlatina  nor  the  dusky,  bluish  red  of 
measles." 

Suhjedive  St/niiitoiiis. — These  are  usually  so  mild  that  children  do  not 
complain.  I  have  seen  cases  of  rubella  in  the  Kaiser  and  Kaiserin  Frederick 
Hospital,  in  Berlin,  while  making  rounds  with  Professor  Baginsky,  which 
were  of  a  very  mild  nature  and  in  which  hardly  any  subjective  symptoms 
were  complained  of. 

The  Fever. — A  peculiarity  of  this  condition  is  that  the  fever  does  not 
correspond  with  the  eruption,  in  intensity.     Von  Xymann  studied  119  cases 


PAT£ 

11 

iZ 

13 

^ff 

/i" 

TE.MP. 
FfiiHR. 

M 

E 

M 

E 

M 

£ 

M 

£• 

M 

£ 

•s 

101°  :i 

fOO'  '•% 

i 

-^ 

1 

r\ 

y—^ 

^^ 

H 

H 

k^ 

s^— 

Fig.  197.— Temperature  Chart.     Case  of  Rubella.      (Original.) 


of  rubella.      lie  found  that  58  cases  showed  no  rise  in  temperature.      In 
the  remaining  (Jl  cases  the  temperature  was  as  follows: — 

In  39  cases  the  highest  record  was  100.4°  F.   (38.0°  C.) 

In  14  cases  the  highest  record  was  101.3°  F.   (38.5°  C.) 

In     6  cases  the  highest  record  was  102.2°  F.   (39.0°  C.) 

In     2  cases  the  highest  record  was  103.1°  F.   (39.5°  C.) 

Fever  never  remains  more  than  four  days  unless  some  complicalion  cr- 
isis. The  pulse  and  respiration  do  not  show  much  change,  but  usually  cor- 
respond with  the  temperature.     Sometimes  a  slight  albuminuria  is  present. 

Desquamation. — A  general  desquamation  is  absent.  Just  as  the  rash 
sj)reads  from  place  to  place  and  is  regional  in  character,  so  also  is  iiie 
desquamation  regional.  There  is  therefore  no  distinct  stage  of  desquama- 
tion that  can  1)0  a])]di('(l  to  the  disease  as  a  whole. 

Differential  Diagnosis. — The  following  distinctive  ])oints  are  taken 
from  Corlett : — 

''First. — That  rubella  is  sometimes  feebly  contagious,  while  measles  is 
always  violently  contagious. 


G26  '-I'lll-^  INFECTIOUS  DISEASES. 

"Second. — The  prodromal  stage  is  always  short  and  quite  insignificant 
in  rubella,  while  in  measles  it  continues  j'rom  three  to  four  days. 

'"Third. — In  measles  the  prodromal  stage  is  usually  accompanied  by 
marked  constitutional  symptoms,  witli  catarrh  of  the  upper  air  passages, 
lacrymation,  photophobia,  and  a  more  or  less  characteristic  eruption  in  the 
mouth,  which  appears  from  twelve  to  forty-eight  hours  before  the  cutaneous 
exanthem.  In  rubella  no  characteristic  prodromata  are  observed,  and  only 
at  the  beginning  of  the  eruptive  stage  is  there  usually  a  slight  hyperaemia  of 
the  conjunctiva',  of  the  faucial  mucous  membrane,  and  rarely  of  the  upper 
air  passages.  On  the  soft  palate  and  uvula  there  is  sometimes  a  punctate  or 
faint  nuicular  enanthem,  which  by  some  is  considered  distinctive.  Even  in 
mild  cases  of  measles  the  disturbance  of  the  mucous  membranes  is  more 
severe  than  in  severe  cases  of  rubella,  and  there  is  always,  so  far  as  I  have 
observed,  a  bluish  or  skim-milk  tint  to  the  mucous  membrane  of  the  mouth, 
which  I  have  never  found  in  rubella.  In  rubella,  sore  throat  is  present  in 
nearly  all  cases,  while  in  measles  sore  throat  is  uncommon. 

''Fourth. — The  eruption  in  rubella  appears  most  frequently  on  the  first 
and  second  day,  rarely  later.  It  often  disappears  from  parts  first  attacked 
before  other  regions  become  involved.  It  is  of  a  pale  red  or  pinkish  color, 
very  rarely  assuming  a  dusky  tint,  and  the  individual  spots  are  surrounded  by 
a  faint  areola,  thus  obscuring  the  outline  of  the  lesion.  The  spots  are 
papulo-macular,  for  the  most  part  round  or  slightly  oval  in  shape,  and 
present  no  tendency  to  form  crescents  or  groupings.  Sometimes  by 
coalescing  they  unite  to  form  extensive  areas,  which  in  all  cases,  either  at 
the  periphery  or  on  more  remote  parts,  are  associated  with  the  discrete,  small 
n;acules  which  give  character  to  the  eruption.  The  rash  rarely  lasts  longer 
than  three  days,  and  most  frequently  it  disappears  on  the  upper  part  of  the 
body  on  the  second;  while  in  measles  the  eruption  alinost  alwaj^s  appears 
on  the  morning  of  the  fourth  day,  sometimes  on  the  third,  and  rarely 
earlier.  In  measles  the  color  is  of  a  dark  or  purplish  red,  and  the  lesions 
are  well  defined,  with  normal  skin  intervening.  They  enlarge  at  the 
periphery  and  show  a  marked  tendency  to  form  grou})s  and  crescents.  These 
are  especially  marked  on  the  face,  neck,  and  upper  ])art  of  the  trunk.  In 
all  cases  the  individual  lesions  are  larger  than  in  rubella;  so  that  the  whole 
surface  of  the  body  mux  be  involved  at  the  same  time,  consequently,  it 
remains  longer  than  that  of  rubella,  lasting  from  four  to  five  days,  or  longer, 
when  defervescence  begins. 

"Fifth. — In  rubella  the  superficial  lymphatic  glands  of  the  neck  arc 
nearly  always  involved,  being  swollen  and  sometimes  painful;  while  in 
measles  marked  or  painful  enlargement  of  the  glands  of  the  neck  is 
decidedly  uncommon. 

"Sixth. — In  rubella  the  temperature  may  be  only  slightly  above  the 
normal  at  any  time  during  the  course  of  the  disease,  and  it  rarely  exceeds 


RUBELLA.  627 

102°  F.  (38.8°  C).  Nor  is  the  temperature  curve  in  any  way  cliaracteristic 
of  the  ati'ection.  Further,  it  is  usually  of  short  duration  and  rarely  contin- 
ues beyond  the  second  or  third  day.  In  measles  fever  is  always  present  and 
the  temperature  is  sometimes  high.  There  is  an  initial  rise  of  temperature 
during  the  prodromal  stage,  which  usually  subsides,  returning  just  previous 
to  the  appearance  of  the  eruption,  and  attaining  its  maximum  at  the  height 
of  the  etiiorescence.  The  fever  may  continue  until  the  seventh  or  eighth 
day. 

"Seventh. — Eubella  is  seldom  accompanied  by  complications  or  fol- 
lowed by  sequela?,  while  in  measles  complications  are  common  and  constitute 
the  most  serious  feature  of  the  disease." 

In  studying  the  above  we  can  readily  see  that  measles  is  very  frequently 
mistaken  for  rubella.  Scarlet  fever  has  a  small  punctate  rash  very  uniform 
in  character.  The  temperature,  and  the  characteristic  throat  and  tongue 
will  usually  differentiate  this  condition. 

Syphilis  is  frequently  mistaken  for  rubella,  but  the  absence  of  the 
characteristic  initial  lesion  will  aid  in  establishing  the  true  diagnosis.  Be- 
fore making  a  positive  diagnosis  we  should  see  that  our  patient  is  not  suffer- 
ing from  a  drug  eruption. 

Complications. — These  are  rarely  seen.  The  disease  is  so  benign  that  it 
rarely  leaves  any  after-effects.  Eecurring  rashes  have  been  described  by 
various  authors,  hence,  a  relapse  is  possible.  This  second  rash  does  not 
differ  in  character  from  the  first.  The  contagious  nature  of  this  condition 
has  been  well  established.  Hatfield  reports^  that  of  196  children  in  an 
asylum,  110  were  affected.  Corlett  believes  that  it  is  as  contagious  as 
measles,  but  the  contagium  retains  its  vitality  longer  and  heuce  resembles 
scarlatina.  The  infectious  nature  of  this  disease  has  been  studied  bv  Ed- 
wards, who  found  that  75  per  cent,  of  cases  in  an  epidemic  in  Philadelphia 
could  be  traced  to  infection  from  the  1)unks  of  ships. 

Course. — Eubella  ruus  a  mild  course.  Cases  seen  by  me  during  an 
epidemic  in  the  winter  of  1903-190-1  remained  ill  about  three  to  four  days, 
rarely  five  days.  Some  authors  state  that  children  with  rul)ella  are  ill  one 
and  two  weeks. 

Prognosis. — This  is  always  good.  With  good  sanitary  surroundings, 
aided  by  careful  diet,  recovery  always  takes  place. 

Treatment. — A  child  with  rubella  should  be  put  to  bed  and  kept  con- 
fined until  all  evidence  of  eruption  has  disappeared.  A  liquid  diet  should 
be  prescribed.  The  gastro-intestinal  tract  must  be  watched ;  the  bowels  and 
kidneys  assisted  if  necessary. 


^  Cliicago  Medical  Examiner,  August,  1S8L 


CHAPTER  A^II. 

MEASLES  (M()KlilJJ>l,  lU'BEOLA). 

Measles  is  an  acute  eruptive  disease  associated  with  fever.  It  is 
caused  b}'  the  invasion  of  a  specific  micro-organism  the  character  of  whicli 
has  not  yet  been  definitely  deteruiined. 

Etiology. — Measles  is  a  contagious  and  to  a  less  extent  an  infectious 
disease.  It  is  usually  communicated  direct  from  person  to  person.  Inter- 
mediate contagion  is  comparatively  rare.  Contagion  is  possible  three  or  four 
days  before  the  rash  appears  on  the  skin,  and  continues  until  desquamation 
has  ceased.  Children  differ  as  to  their  susceptibility,  some  contracting  the 
disease  by  very  short  exposure,  while  others  require  a  longer  and  more  inti- 
mate contact. 

The  disease  can  be  more  readily  conveyed  in  poorly  ventilated  or 
crowded  apartments,  schools,  and  kindergartens,  where  many  children  are 
intimately  associated. 

The  disease  is  characterized  by  coryza,  and  a  congestive  condition  of  the 
conjunctiva,  with  more  or  less  catarrh  of  the  respiratory  tract,  accompanied 
by  an  exanthem.  This  disease  is  always  aecomi)anied  l)y  high  fever.  One 
attack  usually  confers  immunity.  The  mortality  is  usually  low  in  robust 
children.  It  is  as  high  as  30  to  40  per  cent,  in  rickety  and  bottle-fed 
children.  The  danger  is  not  so  much  from  the  measles  as  it  is  from  the 
complications,  notably  broncho-pneumonia  and  laryngeal  croup. 

Period  of  Incubation. — The  period  of  incubation  ranges  between  nine 
and  fourteen  days,  the  average  being  eleven  days.  Some  authors^  give 
eighteen  to  twenty-one  days  as  the  period  of  incubation  when  measles  occurs 
a  second  time. 

Bacteriology. — In  the  blood  of  fatal  cnses,  the  staphylococcus  pyogenes 
albus  and  the  stre])tococcus  p^'ogenes  iwv  foinid.  Claisse-  descril)es  an  acute 
septicemia  found  in  measles  in  very  young  children.  In  these  cases  the 
streptococcus  was  invariably  found. 

Pathology. — In  a  study  of  the  early  mucous  lesions  in  the  mouth 
Slawyk  found  that  the  epithelial  cells  were  thickened  and  in  some  in- 
stances had  undergone  fatty  degeneration.  No  specific  micro-organism  has 
been  found  in  the  lesions.     Frequently  there  is  a  tendency  to  the  formation 


'Graham:      Article  on  "Measles;"    Morrow's  "System  of  Dermatology,"   1894, 
vol.   iii. 

=  Revue  de  ^led.,  :M:»y  10.  1S!)3. 
(628) 


MEASLES. 

Table  No.  86 — Deaths  from  3Ieasles  in  Children  Under  15  Ycurs — Old  City  of  New 


629 

Yorlc. 


Total. 

0 
Year. 

1       \       2 
Year.     Years 

3 

Years. 

4 
Years. 

Under 
0  Yrs. 

5-10        10-15 
Years.    Years. 

1890 

Males 
Females 

381 
313 

121 
99 

139         59 
141         51 

35 
23 

11 
13 

365 
327 

16 
15 

1 

1891 

Males 
Females 

311 
346 

82        116    1     42 
94        138    ,     59 

28         25 
26          17 

293 
334 

18 
12 

1892 

Ma'es 
Females 

448 
410 

151        166 
111        150 

61 
66 

33 
32 

19 
24 

430 
383 

17 
27 

1 

1893 

Males 
Females 

198 
191 

57         85 
54    1      67 

27 
37 

14 
17 

6 
5 

189 

180 

9 
10 

1 

1894 

Males 
Females 

297 

282 

96        108 
88          94 

37 
42 

28 
31 

8 
12 

277 
267 

19 
15 

1 

1895 

Males 
Females 

371 
417 

84 
108 

167 
157 

62 
72 

31 
45 

12        356 
15     !    397 

13 

19 

2 
1 

l>^9(j 

Males 
Females 

352 
353 

99 

88 

119 
133 

69 
77 

30 
31 

19     i    336 
8        337 

15           1 
15           1 

1897 

Males 
Females 

191 
196 

53 
55 

80         30 
79        28 

17 
17 

5         185 

5         184 

! 

6 
10 

2 

1898 

Males 
Females 

252 
190 

76 

48 

112 

88 

39 

28 

11 
13 

8 
8 

246 

185 

6 
5 

1H99 

Males 
Females 

202 
176 

60 
35 

81 
90 

27 
27 

12 

10 

6 
9 

186 
171 

15 
5 

1 

1900 

Males 
Females 

237 
227 

60 
56 

95 

101 

40 

26 

16 

17 

11  222 

12  212 

12 
14 

11 
6 

3 

1 

1901 

^lales 
Females 

149 

118 

37 
24 

53 

48 

26 
25 

12 

12 

10 
3 

138 
112 

ol'  ulcers,  which  extends  to  tlie  doeper  j^arts.  Unua  called  attention  to  the 
tliromljosis  of  superficial  vessels  of  the  skin  in  a  severe  type  of  measles  re- 
sembling smallpo.x.  When  gangrene  existed  streptococci  were  always  pres- 
ent. Corneil  and  Babes  report  a  special  form  of  pneumonia  beginning  as  an 
interstitial  ])n('nmonia  and  later  giving  rise  to  a  fibrinous  effusion  into  the 
alveoli.  Tt  involves  tlie  lyni[)hatic  system,  the  intcrIoI)ular  and  interalveolar 
tissue,  'i'he  toxic  effect  of  the  measles  virus  resembles  pathological  changes 
noted  in  diphtheria.     They  can  be  found  in  the  central  nervous  system.     No 


(530  I'iil^  INFECTIOUS  DISEASES. 

doubt  the  toxin  generated  by  a  specific  organism  simiiar  to  that  oi"  tlic 
Loeffler  bacillus  found  in  diphtheria  causes  the  degenerative  changes. 

Symptoms. — Prodromal  Siaye  or  Period  of  Invasion:  The  first  symp- 
toms are  those  of  an  ordinary  coryza,  sneezing,  dry  cough,  and  watering 
of  the  eyes  (lacrymation),  with  photophobia.  Moderate  fever,  temperature 
from  101°  to  10.^°  F.,  rarely  higher  during  the  first  day.  There  is  some- 
times vomiting. 

This  condition  lasts  about  three  days  and  is  followed  by  the  character- 
istic eruption.  'J'his  eruption  is  first  seen  on  the  face  or  neck  on  the  morning 
of  the  fourth  day.  Very  young  infants  show  extreme  irritability  and  rest- 
lessness. The  tongue  is  covered  ^\■ith  a  white  fur.  'J'he  jjapillae  are  red  and 
swollen.  They  are  not  as  conspicuous  as  in  scarlet  fever.  There  is  intense 
dryness,  and  thirst,  with  marked  anorexia,  and  usually  constipation. 

The  temperature  shows  great  variability.  Wunderlich,  Thomas  and 
Aon  Jurgensen,  who  have  studied  the  temperature  exhaustively,  state  that  it 
cannot  be  considered  characteristic,  owing  to  its  frequent  variations.  The 
tem])erature  after  having  reached  103°  F.  or  even  104°  F.  will  on  the  second 
day  of  the  disrease  drop  to  nearly  normal.  There  is  usually  a  morning  re- 
mission to  the  temperature.  The  temperature  in  a  characteristic  case  is 
sometimes  deceptive,  so  that  after  three  or  four  days  of  illness,  there  may 
be  a  sudden  activity  of  all  symptoms  with  a  rise  of  temperature.  The  tem- 
perature frequently  reaches  105°  F. 

Early  Syniplfjuis  of  Measles. — The  absence  of  the  thick  epidermic  cover- 
ing which  nuisks  the  first  pathological  manifestations  in  the  skin  (exanthem) 
is  more  readily  seen  on  the  delicate  mucous  surfaces  (enanthem). 

The  enanthem  in  measles  has  long  been  known.  It  has  been  studied 
by  Willan,  in  180G;  by  Heim,  in  1813;  in  Dunglison's  "Cyclopajdia  of 
Practical  ilMedicine,"  in  1854;  by  Trousseau,  in  ISliG.  Niemeyer's  "Prac- 
tice of  Medicine,"  1876,  vol.  ii,  p.  538,  mentions  Pehn.  who  studied  an  erup- 
tion in  the  cheek,  gums,  lips,  and  fauces.  Pilliet  and  Barthez,  1854,  and 
Monti,  in  18T3,  devote  considerable  attention  to  the  prodromal  enanthem  of 
measles. 

Flindt,  of  Denmark,  describes  it  at  length  in  the  "8undheds-collegium," 
as  follows : — 

"First  day  of  the  fever:    A  slight,  difl'use  erythenui  of  the  throat. 

"Second  day  of  the  fever:  A  fairly  dark  redness  witbout  marked 
oedema  of  posterior  pharyngo-])alatine  arch  and  tonsils,  which  on  the 
anterior  pab-itinc  arcb  (nrciis  glnss()-]);ibit inus)  and  vchiiii  palati  is  some- 
M'liat  less  deep  in  color  and  of  an  irregularly  dill'usi'd  or  mottled  a])pearance. 
On  the  evening  of  the  second  d;iy  of  tlie  fever  the  mucous  surfaces  of  the 
tonsils,  and  the  ])()stei-ior  ]);d;i(iiic  ai'cli,  have  undergone  l)ut  little  or  no 
change,  appearing  as  a  uniformly  red  erythema,  with  slight  cedema.  On 
the  anterior  surface  of  the  soft  palate,  and  the  posterior  part  of  the  hard 


MEASLES.  631 

palate,  as  well  as  occasionally  on  the  remaining  normal  mucous  surfaces,  a 
distinct  enantliema  appears.  The  lesions  are  round  or  irregular  in  shape,  of 
a  bright  red  color,  having  an  ill  defined  margin,  with  little  or  no  elevation 
at  this  time  above  the  surrounding  surface.  They  range  from  a  pin-head 
to  a  lentil  in  size,  and  occur  singly,  or  are  scattered  irregularly  over  the 
surface.  In  places  there  is  a  tendency  for  the  lesions  to  cluster  in  groups 
and  to  become  blended. 

"They  acquire  a  peculiar  appearance  on  account  of  numerous  small, 
white  glistening  points  (simulating  minute  vesicles),  which  occupy  the 
middle  of  the  small  red  macules.  These  manifestations  in  the  macules  are 
irregularly  grouped.  One  can  see  and  feel  the  minute  vesicles  elevated  above 
the  surrounding  areas.  The  palpebral  conjunctiva  is  hypera^mic  in  its 
entire  extent.  Besides  the  reticular  and  macular  reddening  of  the  con- 
junctiva, which  is  due  to  tlic  disposition  of  the  conjunctival  vessels,  there  are 
also  small,  glistening,  miliary  elevations  similar  to  the  elevations  in  the 
palate. 

"Third  day  of  the  fever:  The  mucous  surfaces  of  the  buccal  cavity, 
which  up  to  this  time  have  been  only  slightly  hypera-mic,  are  now  found  to 
be  invaded  by  the  lesions  previously  described.  These  latter  are  strongly 
marked  over  the  entire  anterior  surface  of  the  velum  palati,  the  glosso- 
})alatine  arch,  and  usually  also  over  the  contiguous  two-thirds  of  the  hard 
palate.  The  red  spots  are  sometimes  very  numerous,  at  other  times  isolated, 
and  again,  by  blending,  they  form  irregular  figures  of  a  stronger  red  than 
])reviously  seen.  Here  and  there  a  faint  appearance  of  the  previously 
described  vesicle-like  formations  is  seen  projecting  al)ove  the  surrounding 
surface.  On  the  other  hand  they  may  also  be  f<nind  on  the  apparently 
normal  mucous  membrane.  Similarly  grouped  spots  with  whitish  vesicles 
now  also  appear  on  the  inner  surface  of  the  cheeks,  csp.'cially  on  the  part 
opposite  the  juxtaposition  of  the  upper  and  lower  molar  teeth. 

"As  a  rule,  the  gums  and  the  inner  surface  of  the  lips  retain  their  nor- 
mal color,  or  at  most  are  only  slightly  hypersemic.  It  is,  indeed,  seldom  that 
the  eruption  appears  on  these  parts.  The  tonsils  and  both  pharyngo- 
palatine  arches  still  remain  red. 

"The  palpebral  conjunctiva  retains,  its  deep  red  color,  but  no  spotS  are 
visible,  excepting  the  minute  vesicles  previously  described.  At  this  time  the 
eruption  breaks  forth  on  the  skin.  On  the  evening  of  the  third  day  there 
is  little  or  no  change  perceptible 

"Fourth  day  of  the  fever:  On  the  palate  and  inner  surface  of  the 
cheeks  the  spots  stand  out  prominentlv,  while  in  many  places  there  is  a 
tendency  to  merge  l)y  enlargement  of  the  individual  lesions,  and  on  the 
surfaces  last  invaded  they  are  more  copious  than  ever.  The  conjunctival 
exanthem  is  now  disappearing.  On  the  evening  of  this  day  there  is  no 
chancre  noted. 


632  TliE  INFECTIOUS  DISEASES. 

''Fifth  day  of  the  fever:  The  exanthein  in  the  buccal  cavity  is  more 
marked  than  heretofore.  Frequently  at  this  time  there  appear  faint-reddish 
spots  on  the  mucous  surfaces  of  the  lips,  even  extending  to  the  exposed 
cutaneous  margin.  On  the  gums  they  are  seldom  present  and  never  distinct. 
The  hyperemia  of  the  posterior  fauces  remains  unchanged.  The  skin 
exanthem  begins  to  fade,  and  the  temperature  falls. 

"Sixth  day  of  tbc  fever:  The  exauthem  of  the  mucous  surfaces  is  no 
longer  visible,  except  a  slight  diffuse  redness  of  the  palate  and  the  inner 
surface  of  tlie  cheeks.      Fever  ends." 

This  characteristic  enanthem  is  seldom  absent.  Slawyk^  found  it 
present  in  90  per  cent,  of  all  cases  examined. 

Koplik  described  these  symptoms-  and  to  him  belongs  the  credit  of 
having  po2)ularized  the  enanthem.  It  is  generally  known  as  Koplik's  sign. 
The  spots  are  best  seen  on  the  inside  of  the  cheeks  opposite  the  molar 
teeth,  although  I  have  seen  them  very  clearly  defined  on  the  mucous  mem- 
brane of  the  upper  lip  corresponding  to  the  incisors. 

The  patient  must  l)e  examined  in  a  strong  sunlight  or  with  a  good 
electric  light.     A  yellow  gaslight,  for  instance,  is  very  unsatisfactory. 

Differential  Value  of  tliis  iSign. — This  enanthem  is  of  great  value 
in  differentiating  measles  from  other  exanthemata,  notably,  however,  from 
antitoxin  rashes,  drug  eruptions,  and  eruptions  associated  with  toxgemia 
from  gastric  fevers. 

Period  of  Effloresence  (Eruptive  Stage). — The  eruption  usually  appears 
on  the  fourth  day  of  the  disease.  Sometimes  it  appears  as  early  as  the 
third  and  sometimes  as  late  as  the  fifth  day.  The  first  spots  appear  on  the 
forehead  or  the  temples,  behind  the  ears,  and  on  the  sides  of  the  neck. 
Later,  spots  appear  about  the  eyes,  mouth,  and  chin.  When  the  rash  is  at 
its  height  then  a  crescentic  character,  first  described  by  Willan,  will  be 
noticed.  The  constitutional  disturbances  increase  in  severity.  The  cough 
is  more  pronounced  and  there  is  a  decided  interference  with  the  respiration. 
Nose  bleed  is  quite  frequent.  Constipation  is  usually  followed  by  very  loose 
bowels. 

The  Rash. — The  rash  is  of  a  dark  red,  sometimes  a  purplish  color,  of  a 
round,  oval  or  irregular  shape.  The  skin  between  the  rash  remains 
intact,  although  the  face  has  a  puffy  cedematous  appearance.  The  eruption 
extends  over  the  trunk  and  extremities,  including  the  palms  and  soles,  the 
arms  and  legs,  the  forearms  and  legs  being  the  last  to  l)ecome  affected. 

When  the  rash  reaches  its  height  the  constitutional  sym])toins  subside. 
Jt  is  not  infrequent  to  see  a  normal  tciuperature  two  clays  after  the  rash  has 
coniplelelij  covered  the  hodij.     In  some  instances  there  is  a  crisis,  although 


I 


'  Slawyk :     Dent,  iiipd.  Woch.,  April  28,  1898. 

*  Archives  of  Pediatries,  Ueeember,  18'JG;    Medieal  Record,  1898. 


MExYSLES.  633 

the  usual  rule  is  for  the  temperature  to  fall  gradually  by  lysis.  A  sub- 
normal temijerature  frequently  follows  and  accompanies  the  period  of  con- 
valescence and  until  the  patient  is  normal. 

The  catarrhal  symptoms  continue  to  increase  in  severity  with  the  devel- 
opment of  the  rash. 

There  are  moist  rales  heard  on  auscultation.  The  sputum  as  well  as  the 
nasal  discharge  become  sero-purident.  A  bronchitis  or  a  pneumonia  should 
be  suspected,  if  the  respiration  is  exaggerated.  The  pulse-respiration  ratio 
will  he  found  of  great  value  in  diagnosing  latent  pneumonia.  The  urine 
will  show  the  excess  of  urates  and  sometimes  transitory  albuminuria  or 
liyaline  casts  may  be  found.  The  diazo  reaction  is  sometimes  noted,  l)ut  it 
does  not  teach  us  anything  of  value  in  either  the  diagnosis  or  prognosis. 
This  stage  of  the  disease  rarely  lasts  more  than  from  four  to  six  days. 

Stage  of  Desquamation  or  Convalescent  Period.- — The  eruption  on  the 
skin  of  the  face,  neck,  and  upper  part  of  the  chest  fades  and  there  is  a  slight 
branny  desquamation.  This  is  less  marked  than  in  scarlet  fever,  and  is  so 
fine  on  the  trunk  and  extremities  that  it  may  be  unobserved.  It  is  best  seen 
on  tite  sides  of  the  nose,  temples  and  chin.  Large,  flahy  scales  are  rarely 
met  with  in  measles.  After  the  eruption  disappears,  a  certain  amount  of 
pigment  remains  for  a  week  or  two  where  the  rash  existed. 

Atypical  or  Anomalous  Conditions. — Certain  symptoms  of  normal 
measles  vary  in  different  epidemics,  although  the  nuijority  of  cases  present 
distinct  clinical  features.  Predisposing  factors,  such  as  rickets  and  scurvy, 
possibly  tuberculosis,  will  frequently  alter  the  type  of  the  disease  or 
modify  the  symptoms.  Edgar^  reports  an  epidemic  of  42'3  cases  in  which 
123  adhered  to  the  regular  type. 

Mild  Forms. — ]\Ieasles  may  be  present  without  catarrhal  symptoms.  In 
such  cases  fever  may  be  slight  or  absent.  In  other  cases  the  catarrhal 
symptoms  are  severe  while  the  cutaneous  exanthem  is  almost  ivholly  absent 
(morbilli  sine  morbillis).  Such  cases  might  readily  escape  notice  unless 
they  partake  of  a  series  during  an  epidemic,  in  which  both  the  mild  and 
the  severe  type  are  found. 

Relapsing  Form  or  Second  Attack. — A  relapse  is  said  to  occur  in  rare 
instances,  alter  the  exanthem  has  disappeared.  When  the  second  rash 
appears  there  is  a  return  of  fever  and  also  the  other  constitutional  symp- 
toms. Occurring  measles  is  often  a  very  serious  matter,  owing  to  the 
already  weakened  state,  resulting  from  the  first  invasion. 

Oork'tt  douljts  tlie  so-called  re]a})ses  and  believes  that  they  are  due  to 
a  direct  rcintoxication  Ity  tlie  specific  virus. 

Severe  or  Malignant  Forms. — "Malignant  measles  is  that  form  in  which 
tliere  is  a  very  liigh  fever,  rapid  pulse,  labored  breathing,  and  great  prostra- 


^Can.  Med.  Record,  December,  1892. 


G3-4 


THE  INFECTIOUS  DISEASES. 


tioii.      The  fatal  ist^ue  most  frequently  occurs  on  the  second  day  of  the 
exanthem.      We  frequently  meet  with  a  typhoidal  or  a  toxic  form  in  which    J 
the  symptoms  are  of  a  most  malignant  character.      The  mouth  becomes     ■ 
parched  and  the  tongue  brown  and  dry,  resembling  a  typical  typhoidal  con- 
dition. 

The  bowels  are  loose  and  tlie  quantity  of  urine  diminished.  Convul- 
sions resulting  from  the  general  tox;cmia  are  very  common.  It  is  usually 
fatal  and  rarely  ends  in  recovery.  A\'here  there  is  severe  respiratory  dis- 
turbance, with  difficult  breatbing,  it  is  called  the  siijjocatice  form.  In  this 
form  we  have  principally  cough  and  expectoration  with  severe  dyspnoea. 

The  patient  is  cyanotic.  Mucous  rales  are  heard  early  in  the  disease, 
and  it  not  infrequently  ends  in  a  bnmclio-pneumonia. 

Hsemorrhagic  forms,  kno\vn  as  the  black  measles,  are  frequently  de- 
scribed. The  mild  form  of  hiumorrhagic  measles  has  been  described  by 
various  authors.  Edgar  reports  200  cases  out  of  433,  or  47  per  cent,  of  the 
hiemorrhagic  form.  Holt  found  it  in  5  per  cent,  of  his  cases.  The  cutane- 
ous exanthein  assumes  a  dark  bluish  or  purplish  tint,  which  gradually  deep- 


TabIjE  No.  87. — Showing  503  Cases  of  3Ieasles  and  Complications.,  Treated  in  the  Biverside 
Hospital,  Neil)  York  City,  During  the  3Iontlis  of  January  to  July,  Inclusive. 


No.  of  Cases. 

Uucompli- 
cated  Measles. 

Measles 

and 

Diphtheria. 

Measles 

and 

Pneumonia. 

Measles,  Sca--- 
let  Fever  and 
Diphtheria. 

Measles  and 
Scarlet  Fever. 

1SM)4 

Cases 

Deaths 

Cases 

1 
Deaths 

1 

Cases 
2 

Deaths 
2 

6' 

Cases 

Deaths 

Cases 

Deaths 

Cases 

Deaths 

Jan. 

34 
70 

4 

8 

31 
62 

1 

1 

1 

1 

Feb. 

7 

1           1 

1 
4    1      4 

Mar. 

133        14 

111 

84 

2 
0 

9 

2 

1 

7 

1 

Apr. 

103 
10(3 

15 



16 

8 

8 

1 

10 

7 

1 
1 

0 
1 

May- 

77 

2 

13 

4 

13 

8 

2 

1 

June 

37 

8 

23 

0 

7 

3 
1 

7 

5 
4 

July 

20 

5 

12 

0 

3 

5 

Total 
Cases 

503 

400 

49 

30 

41 

4 

9 

Total 
Deaths 

70 

. 

6 

30 

2 

2 

MEASLES. 


635 


ens  as  the  process  continues,  to  a  bhiisli-ljlack  color.  Frequentl}^  the  whole 
bod}'  shows  a  tendency  to  bleed.  Thus  the  mucous  surfaces  are  implicated, 
giving  rise  to  epistaxis,  bleeding  from  the  gums,  dysentery  stools  and 
hemorrhages  from  the  genito-urinary  tract.  Where  a  tendency  to  haemor- 
rhage exists,  as  in  hiemophilic  subjects  (bleeders),  they  are  especially  predis- 
posed to  the  hemorrhagic  form. 


Fig.  19S. — A  Case  of  ^Malignant  Measles,  complicated  by  Diphtheria  and 
ending  with  Empyema.  ^Nlale  child,  .3  years  old.  Septic  from  beginning. 
Fatal  termination,  hfeen  in  my  service  at  Riverside  Hof^pital,  New  York 
City.     (Original.) 


Complications. — I'nhitonanj :  There  seems  to  he  a  predisposition  to 
pulmonary  disease,  commencing  witli  a  bronchial  catarrh,  especially  in  those 
chihlren  with  feel)le  resisting  ])owei'.  'V\\o  inflammatory  condition  extends 
inlo  tlie  smaller  rainifications  of  llie  bronchial  tubes,  causing  capillary 
bronchitis.  When  this  occurs  it  should  be  viewed  with  alarm.  The  child 
shows  dyspnoea  and  adynamic  symptoms,  owing  to   difficult  oxygenation. 


636 


THE  INFECTIOUS  DISEASES. 


The  Larynx. — One  of  the  most  frequent  and  fatal  complications  met 
with  in  children  is  laryngitis.    This  may  be : — 

(a)  Spasmodic. 

(h)  Phlegmonous. 

(c)  Membranous. 

The  last  named  complication  is  the  one  most  frequently  met  with,  espe- 
cially in  institutions.  It  is  most  common  during  the  eruptive  stage  as  early 
as  the  third  or  fourth  day.  The  symptoms  are  the  same  as  those  met  with 
in  laryngeal  diphtheria  accompanied  by  stenosis  of  the  larynx. 

The  Klebs-Loeltler  bacillus  is  sometimes  found  on  bacteriological  ex- 
amination of  the  pseudo-membrane.  It  can  be  found  in  G  to  10  per  cent,  of 
all  cases  of  membranous  laryngitis. 


Fig.  199. — Temperature  Chart  from  a  Case  of  Measles  Complicated  by 
Broncho-pneumonia.  Seen  during  my  service  at  the  Riverside  Hospital,  New- 
York  City.     (Original.) 

Broncho-pneumonia. — This  is  the  most  frequent  and  the  most  fatal 
complication  of  measles.  Houl^  found  it  in  one-fifth  of  all  of  his  cases.  In 
the  Nursery  and  Child's  Hospital  of  New  York,  Holt  observed  it  in  40  per 
cent,  of  all  cases.  This  infection  can  invariably  be  traced  to  the  presence  of 
various  organisms  of  which  the  pneumococcus  of  Friedlander,  and  the 
micrococcus  of  Frankel  play  a  conspicuous  role. 

There  is  marked  retraction  of  the  chest  in  addition  to  the  usual  signs 
of  pneumonia.  The  physical  examination  shoAvs  widely  disseminated  sub- 
crepitant  I'ales  which  soon  gi\c  way  to  definite  resonance,  bronchial  breath- 
ing, and  fine  crepitations.  In  young  children  its  onset  is  acute,  with  rapid 
pulmonary  congestion,  and  it  usually  terminates  fatally  within  two  or  three 


'  Wien.  klin.  Rund.,  1897,  vol.  xi,  p.  833. 


MEASLES. 


637 


days.    When  the  condition  extends  over  a  more  subacute  course,  it  may  lead 
to  caseous  pneumonia  or  pulmonary  tuberculosis. 

Ca.se  I.  Kate  A.,  aged  twenty-one  months.  Child  was  admitted  to  the  Riverside 
Hospital  August  25,  1904,  in  fairly  good  condition,  with  temperature  104°  F.,  pulse 
136,  respiration  36.  Sick  since  August  22d.  Child  had  a  moderately  severe  cough  on 
admission.  On  August  26th  cough  increased  in  severity,  breathing  short,  rapid  and 
labored. 

Physical  examination  showed  only  a  few  coarse  rales  at  upper  part  of  chest 
posteriorly,  with  slight  dullness,  but  no  bronchial  breathing. 


\9.oA. 

1 

fiu 

^ 

29 

30 

31 

1 

2 

3 

4 

Cent. 

Fahr. 

AM>M 

am:pm 

AMiPM 

am:pm 

AMiPM 

am:pk 

am:pm 

39°  ~ 

•8 

-102°  •* 

•  A 

\ 

38'~ 

•8 
•6 

\ 

^ 

•8 
•6 

-100° -2 

:\ 

/ 

^ 

■  \  I 

37  ~ 

•8 
•6 

-09  -a 

• 

V; 

n 

A 

•  8 
•6 

: 

\r 

\.     ■ 

-98'  ••■i 

v. 

\      .^ 

-^^ 

-  -8 
•fl 

-  oM 

-97  -2 

•8 

•e 
-96° -2 

\ 

- 

Pulse 
per  minute 

IT 

1 

rr 

u: 

rr 

C 

oc 

o 

rvj 

Q  -0 

litsfpirationa 
per  minute 

«-d  LC 

in 

c 

rr 

ex 

Fig.  200. — Temperature  Chart  from  a  Case  of  Measles  Complicated  by 
Broncho-pneumonia.  Seen  during  my  service  at  the  Eiverside  Hospital, 
New  York  City.     (Original. )' 


Well-marked  dullness  over  the  right  base  posteriorly,  with  bronchial  voice  and 
breatliing.  Left  base  behind  gave  slight  dullness  with  many  coarse  rales.  No  bron- 
chial breathing. 

On  August  28th,  pleuritic  friction  sounds  over  right  base  posteriorly. 

On  August  31st,  percussion  gave  marked  dullness,  almost  flatness  over  this 
area,  extending  slightly  above  the  infenor  angle  of  right  scapula.  Over  this  area, 
marked  bronchial  voice  and  breathing. 


'I  am  indebted  to  T)rs.  Alfred  Helgeson,  Bruno  llorwicz,  a'ld  Wm.  Ogden  Lord  for 
clinical  histories,  charts,  and  statistics. 


638  THE  IXFECTTOrS  DISEASES. 

On  September  1st,  bloody  scrum  obtained  upon  aspiration. 

On  September  3d,  scrum  obtained  by  aspiration,  bloody  with  slight  turbidity. 
General  condition  continued  the  same  up  to  .September  Otli.  On  this  day  a  drop  in 
the  temperature  from  10-°  to  !)7.()°  ¥.  occuii<'d.  (iiild  appeared  brighter,  slept  well 
and  has  a  good  appetite. 

During  the  last  two  days,  fluctuations  in  temperature  have  occurred,  ranging 
from  98°  to  101°  F.   (evening  rise). 

This  fluctuation  of  temperature  continued  up  to  September  14th.  On  this  date 
there  was  an  evening  rise  to  99°  F.  only,  and  since  then,  the  highest  rise  has  been 
99'/5°  F.  The  jjulse  has  improved  much  in  quality.  Respirations  have  gradually  di- 
minished in  frecjucncy.  Tlie  child  was  aspirated  on  the  13th,  but  no  pus  or  serum 
was  obtained.  Dullness  was  diminished  over  right  base  posteriorly  and  bronchial 
breathing  was  present  onh'  over  a  small  area  at  base  of  light  lung.  Child  at  present 
sits  up,  has  good  aj)i)etite,  and  sleeps  well. 

Case  II.  L.  Z.,  age  eight  months.  Admitted  to  the  Riverside  Hospital  on  August 
29th,  having  been  ill  since  the  21st.  Upon  adyiission  showed  characteristic  symptoms 
of  broncho-pneimionia  with  temperature  101.4°  F.,  pulse,  150;  respiration,  56.  Upon 
examination,  dullness  was  present  over  riglit  base  behind,  with  bronchial  voice  and 
breathing.  Many  coarse  rales  were  heard  over  both  lungs  behind  as  well  as  in  front. 
There  was  a  pleuritic  friction  sound  over  the  consolidated  area.  No  signs  of  effusion. 
Child  improved  riipidly,  and  upon  September  3d,  the  bronchial  breathing  had  disap- 
peared and  only  signs  were  coarse  rales  over  both  bases  behind.      Recovery. 

Otitis  Coiiiplicatinfj  MeasJcs.'^ — A  very  frcM|iu'nt  sequela  is  acute  otitis. 
If,  after  several  days  of  apparent  convaleseenee  the  child  is  irritahle,  restless 
at  night  and  feverish,  and  cries  cont'nuously,  a  careful  examination  of  the 
ears  sliould  he  made.  As  a  rule  our  attention  is  first  directed  to  this  con- 
dition after  the  cavity  of  the  middle  ear  is  filled  with  the  discharo-e,  and 
tiiere  is  a  spontaneous  discharge  of  pus. 

Siegfried  Weiss-  calls  attention  to  the  method  of  pro])hyla.\is  in  this 
condition.  He  believes  that  with  good  care  we  can  prevent  and  abort  this 
complication.  Tol)eitz  believes  that  in  measles  we  are  dealing  with  a  i)ri- 
mary  enanthematous  disease  of  the  middle  ear. 

In  a  post-mortem  study  of  i)5  cases,  pathological  changes  affecting  the 
ear  showed  the  destructive  tendency  due  to  the  disease  itself. 

Tobeitz  found  that  .SG  jx-r  cent,  of  fatal  cases  of  measles  showed  ear  com- 
jdications.  Bezold  in  a  study  of  18  fatal  cases  of  measles  noted  ear  disease 
in  IT,  or  about  95  per  cent.  Weiss  studied  11-3  cases  in  which  there  were 
ear  complications,  and  after  careful  ])rophylactic  treatment  he  had  only  0.6 
per  cent,  of  ear  comjjlications.  Weiss's  jjrophyhutic  method  consists  in  ap- 
])lying  a  1  j)er  cent,  yellow  ])recipitate  ointment  on  a  sterile  swab  to  the 
nostrils.  By  this  method  he  removes  the  dried  and  fiuid  secretions  from  the 
nose  mechanically.  Another  method  of  Weiss'  consists  in  allowing  1  or  3 
drops  of  y^  per  cent,  nitrate  of  silver  solution  to  drop  into  the  nostril.    In 


'  Read  chapter  on  "Otitis.'" 

-  Wiener  Medicinische  Wochenschrift,  No.  52,  1900. 


MEASLES. 


639 


this  manner  he  Ijelieves  we  can  destroy  the  specific  infectious  material. 
Hayek  has  lono;  advocated  this  method  in  the  treatment  of  chronic  rhinitis 
in  children.  In  using  the  salve  or  the  silver  nitrate  solution  Weiss  found 
that  if  it  was  applied  three  or  four  times  a  day,  the  percentage  of  compli- 
cations was  ijreatlv  reduced. 


Table  No.  88. — Measles  Stat  sties  Shotcing 
Ear  Complications,  Riverside  Hospital. 


,  Of, ,                    Number  of 
'•""'•                       Cases. 

Measles  and 
Otitis. 

January 

31 

6 

February 

74 

11 

March 

127 

10 

April 

101 

14 

Total 

383 

41 

Empyema. — Empyema  is  occasionally  met  with  during  the  course  of 
measles.  As  there  seems  to  be  a  decided  tendency  to  suppurative  formations, 
it  is  well  to  inspect  the  thorax  and  be  sure  that  we  can  exclude  empyema. 
This  should  be  borne  in  mind  if  cough  exists  associated  with  fever.  I  have 
seen  empyema  complicating  measles  in  about  2  per  cent,  of  my  cases.  When 
the  exploratory  puncture  shows  pus  tlie  treatment  is  tlie  same  as  that  given  in 
the  chapter  on  "Empyema." 

The  Eyes. — Severe  inflammatory  and  destructive  changes  are  met  with 
in  measles.  Abscesses  of  the  conjunctiva  or  keratitis,  resulting  in  ulceration 
of  the  cornea,  are  sometimes  seen.  In  other  cases  it  may  extend  to  the 
antrum  or,  if  the  mastoid  cells  are  involved,  it  can  result  in  meningitis, 
cereljral  abscess,  or  pyaemia.  In  very  young  children  the  petroniastoid 
suture,  which  at  this  time  is  still  patent,  allows  free  access  of  pus  into  the 
cranial  cavity  from  the  middle  ear.  Xot  infrequently  this  condition  leads 
to  actual  deafness. 

Immunity. — One  attack  of  measles  usually  confers  immunity  for  life. 
Second  attacks  are,  however,  possible,  and  third  attacks  have  also  been  re- 
]iorted  as  instances  of  rare  conditions. 

^Measles  is  rarely  seen  in  infants  under  1  year.  ]\[ayr  observed  that  of 
10  nurslings  exposed  to  measles,  only  one  contracted  the  disease.  I  have 
rarely  met  with  infectious  diseases  in  liealthy  breast-fed  infants.  There 
seems  to  he  some  nntito.ric  property  conveyed  to  the  iiiirslng  infant  throiiyJt 
the  serum  contained  in  the  hreast-mitk  of  its  mother. 


640  THE  INFEC'TIOL'S  DISEASES. 

At  the  Eiverside  Hospital  I  liavo  seen  nursing  infants,  in  the  measles 
wards,  that  had  heen  exposed  and  did  not  contract  the  disease. 

Iniinunity  can  l)e  conveyed  l)y  a  mother  who  has  liad  measles,  through 
lier  milk,  Init  how  long  this  iiiiiiiunity  lasts  rcmuins  still  to  he  investigated. 

Diagnosis. — An  ordinary  cold  with  coryza,  as  met  with  in  influenza,  is 
sometimes  confusing.  Mistakes  will  occur  unless  we  are  careful  to  note  the 
enanthem  which  is  absent  in  influenza.  The  rise  of  temperature  is  less 
marked  in  influenza  than  in  measles. 

The  diazo  reaction  is  sometimes  observed  in  cases  of  measles.  By  its 
presence  we  cannot,  however,  diagnose  measles. 

Drug  Eruptions. — Some  eruptions  resend^ling  measles  are  caused  by 
quinine  and  antipyrin.  The  internal  use  of  chloral  is  sometimes  followed 
by  an  eruption.     Cubebs  and  copaiba  give  an  eruption  simulating  measles.^ 

Bites  of  insects,  especially  bedbugs,  fleas,  and  mosquitoes,  sometimes 
produce  an  eruption  which  resembles  measles.  As  there  is  no  febrile  dis- 
turbance or  any  enanthem  the  differential  diagnosis  is  easily  made.  The 
injection  of  antitoxin  and  antistreptococcic  serum  sometimes  produces  an 
erui)tion  which-  is  morbilliform  in  character. 

Course. — As  a  rule  three  weeks  should  elapse  before  a  case  of  measles 
is  j^ermitted  to  return  to  healthy  children.  The  cjuarantine  should  be  ex- 
tended over  this  length  of.  time.  This  applies  to  institutions  as  well  as  to 
private  families.  Isolation  should  be  continued  if  a  case  suffers  from  any 
complication  associated  with  the  primary  measles.  In  other  words,  measles 
otitis,  measles  vaginitis,  or  .any  other  complication,  requires  isolation. 

Prognosis. — When  reasonable  care  is  taken,  then  this  is  one  of  the  least 
fatal  of  infectious  diseases.  The  vital  point  consists  in  guarding  the  patient 
against  unnecessary  exposures  and  attending  to  all  functional  disturbances. 
With  proper  attention  to  the  diet  and  symptomatic  treatment  when  neces- 
sary, there  should  be  little  or  no  trouble  experienced.  If  the  fever  declines 
after  the  full  develojnnent  of  the  exanthem,  the  prognosis  is  good. 

If  croup  and  diphtheria  com])licato  measles,  then  the  prognosis  is  al- 
ways grave.  Broncho-pneumonia  is  usually  fatal  in  one-third  to  one-half 
of  all  cases.  Sometimes  a  l)roncho-pneumonia  will  be  followed  by  tuber- 
culosis. Diarrhoea  with  or  without  bloody  stools  should  always  be  looked 
upon  as  a  serious  coriiplication. 

Treatment. — In  the  treatment  of  measles  certain  rules  should  in- 
variably be  followed : — 

(a)  Hygienic. 

(b)  Dietetic. 

(c)  Medicinal. 

Hygienic  Treatment. — The  temperature  of  the  room  should  always  bo 


'P.  A.  Morrow:       "Drug  Eruptions,'"  Now  Yoik,   1887. 


MEASLES.  G41 

uuiform,  no  less  than  68°  F.  and  never  more  than  74°  F.  Modern  clinicians 
assert  that  the  former  method  in  vogue,  oi  bundling  up  the  body  and  keeping 
the  air  of  the  room  vcrv  hot,  prochices  a  certain  amount  of  susceptibility  to 
respiratory  diseases.  In  this  manner,  we  invite  complications  rather  than 
prevent  them.  The  body  of  the  child  may  be  sponged  with  tepid  or  warui 
water,  and  fresh  linen  can  be  given  every  day. 

Overheated  rooms  cause  more  trouble  during  treatment  of  respiratory 
affections  than  any  other  factor. 

Light  of  the  Room. — Careful  observers  have  noted  that  the  light  in 
the  room  has  absolutely  nothing  to  do  with  the  eyes.  Owing  to  the  in- 
flammatory state  of  the  eyes,  there  is  a  normal  photophobic  condition.  Xo 
one  would  think  of  putting  a  child  in  the  beginning  of  measles  in  a 
glaring  sunlight,  but  rather  with  its  hack  to  the  light.  At  the  measles  pa- 
vilion in  Berlin,  under  the  supervision  of  Professor  Baginsky,  the  hygienic 
conditions  are  perfect.  Plenty  of  fresh  air  is  admitted  and  also  light.  I 
have  frequently  had  the  pleasure  of  making  rounds  in  the  wards  of  this 
pavilion  with  Professor  Baginsky,  and  noted  the  al)ove-named  conditions. 
We  do  not  darken  the  windows  in  the  measles  wards  at  the  Kiverside  Hos- 
pital of  Xew  York  City,  and  the  hygienic  conditions  regarding  fresh  air  and 
fresh  linen  have  been  excellent  during  my  term  of  service  there. 

Dietetic  Treatment. — We  must  not  forget  that  in  all  febrile  conditions 
the  digestive  function  is  impaired.  The  diet  must  be  so  regulated  that  there 
is  proper  assimilation.  If  subnormal  conditions  i:>revail,  we  must  order  a 
smaller  quantity  of  food  and  allow  a  longer  interval  between  feedings. 

A  baby  receiving  pure  milk  should  receive  oue-half  milk  and  one-half 
oatmeal  water,  and  if  it  has  l^een  fed  every  three  hours  when  in  good  health, 
then  it  is  wise  to  try  to  feed  every  four  or  five  hours  during  the  febrile  stage 
of  measles.  An  important  point  to  remember  is  that  liquids  are  an  im- 
portant part  of  the  treatment.  Soups,  acidulated  waters,  and  carbonated 
waters  are  grateful  and  indicated.  Orangeade  and  lemonade  are  grateful, 
especially  to  relieve  thirst.  If  the  child  is  older  and  has  been  fed  on  solid 
food  when  in  health,  then  all  solids  should  1)e  discontinued  and  liquid  food 
substituted.     Water  should  be  given  in  large  (juantities. 

Medicinal  Treatment. — If  the  eruption  is  tardy  in  appearing  then  a 
mustard  foot-bath,  using  a  tablespoonful  of  mustard  in  a  foot-tub  of  warm 
water,  100°  F.,  and  adding  warm  water  gradually  until  the  temperature  is 
about  105°  F.,  will  frequently  hasten  the  appearance  of  the  rash.  This  is 
as  hot  as  the  child  can  stand  it  for  a  few  minutes.  If  there  is  a  general 
depression  of  the  vital  powers,  then  give  spir.  mindererus,  a  teaspoonful 
every  hour,  until  perspiration  is  active.  This  will  also  frequently  hasten 
the  appearance  of  the  rash.  One  of  my  favorite  drugs  is  tincture  of  aconite, 
in  1-drop  doses,  if  the  fever  is  very  high. 


642  THE  INFECTIOUS  DISEASES. 

Pneumonia  requires  the  same  care  and  treatment  as  if  it  were  not  a 
complication  or  a  sequela  to  this  disease.     (See  chapter  on  "Pneumonia.") 

Diphtheria  calls  for  the  same  treatment  as  if  it  was  not  associated  with 
measles. 

Immunity  from  Diplitheriu. — An  injection  of  300  to  500  antitoxin 
units  will  confer  immunity  from  diphtheria  in  a  case  of  measles. 

The  urine  must  be  frequently  examined  for  a  possible  nephritis  and 
treated  accordingly. 

Convulsions  frequently  usher  in  the  disease  and  should  be  very  care- 
fully attended  by  rest,  sinapisms,  enemata  of  chloral,  and  possibly  a  few 
leeches  to  the  neck. 

Epistaxis  is  usually  an  early  but  passing  symptom,  but  if  persistent, 
it  should  be  treated  on  general  principles  and  the  cause  looked  into.  The 
congestion  during  an  attack  of  measles  has  frequently  excited  an  otherwise 
quiet  polypus  to  activity  and  caused  alarming  haemorrhages. 

For  the  relief  of  the  cough  I  usually  give : — 

3  Amraon.    bromid 9  i j  3.00 

Syr.  liquorit I]     or      25.00 

Decoct,    althse ad  gij  50.00 

M.     Teaspoonful  every  hour,  for  a  cliild  1  year  old,  until  relieved. 

For  a  child  2  years  old: — 

IJ  Codeine    2  grains 

Saccli.    alb 1  V2  drachms 

M.  Divide  in  chart  No.  X.  Sig. :  One  powder  every  two  hours  until  cough  is 
relieved. 

Summary  of  Treatment. — Give  the  child  excellent  hygiene — fresh  air — 
protect  the  body  with  clean  linen.  Guard  against  draughts.  Isolate  the 
patient. 

Do  not  give  solid  food;  liquid  diet  only,  soups,  broths,  milk,  butter- 
milk if  tolerated,  etc. 

Do  not  give  useless  drugs.  Treat  symptoms,  such  as  hyperpyrexia, 
constipation,  suppression  of  urine,  and  assist  the  cmunctories.  The  greatest 
part  of  the  treatment  is  the  management  of  convalescence — codliver-oil,  iron. 
Fellows'  compound  syrup  of  hypophosphites,  malt  preparations,  cereals, 
butter,  eggs,  and  cream;  meat  sparingly;  all  green  'Vegetables;  oranges  and 
lemons. 

Health  can  be  restored  by  cautious  management  during  the  stage  of 
convalescence.  When  cough  remains  and  symptoms  point  to  the  beginning 
of  tuberculosis,  we  must  not  lose  sight  of  the  fact  that  more  can  be  accom- 
plished by  climatic  treatment — out  of  doors,  in  the  country — than  by  in- 
door treatment.  Complete  change  of  air,  to  a  more  even  climate  like 
Denver,  Colo.,  New  Mexico,  or  Florida,  will  frequently  restore  the  lungs  to 
their  normal  condition. 


CHAPTEK  IX. 
SCARLET  FEVER  (SCARLATINA). 

Scarlet  fever  is  an  acute  infections,  specific  and  contagious  disease. 
The  infection  exists  from  the  earliest  symptoms  and  continues  long  after 
convalescence  has  been  established.  If  a  child  has  been  exposed  to  scarlet 
fever,  it  should  not  be  considered  out  of  danger  until  eight  or  ten  days  have 
passed,  and  then  only  if  there  is  no  fever  or  throat  manifestations  visible. 
This  disease  is  usually  ushered  in  by  vomiting  and  sore  throat,  accompanied 
by  fever.     If  the  child  is  old  enough  it  will  complain  of  headaches. 

The  pulse-rate  will  be  accelerated,  and  there  is  usually  on  the  second  day 
a  distinct  eruption  visible.  This  disease  presents  several  types :  the  mildest 
form,  known  as  Scarlatina  Simplex  or  the  benign  form,  and  the  most  ma- 
lignant type,  Scarlatina  Maligna,  called  by  the  French  "Foudroyante." 

There  are  a  great  many  varieties  between  the  two  types  just  men- 
tioned, so  that  any  sharp  differentiation  is  quite  impossible. 

Clinically,  we  note  three  distinct  types: — 

1.  The  moderate  or  mild. 

2.  The  severe. 

3.  The  malignant  or  cerebral. 

I  prefer  the  classification  given  by  Corlett^ : — 

(a)  Simple. 
(h)  Septic. 
(c)  Toxic. 

Etiology. — Scaiiet  Fever  and  Mill-:  HalP  in  a  very  interesting  article, 
found,  after  an  extensive  review  of  the  literature,  that,  "while  scarlet  fever 
occurs  in  epidemic  form  in  those  countries  where  cows'  milk  forms  a 
staple  article  of  food,  especially  among  children,  it  does  not  occur  in  coun- 
tries where  cows'  milk  is  not  used  as  a  food,  or  where  children  are  raised 
on  mother's  milk  only."  This  is  true  of  Japan,  where  cows'  milk  is  not 
used  and  domestic  animals  are  scarce,  and  it  is  true  in  India,  also,  where, 
though  cows'  milk  is'used,  the  children  are  nursed  by  their  mothers  until 
they  are  3  or  4  or  even  G  years  of  age. 

While  this  immunity  from  scarlet  fever,  together  with  the  absence 
of  cows'  milk  as  an  article  of  food,  may  be  simply  a  coincidence  otherwise 


'In  his  exeellcnt  tro-atiso  on  ilio  "Afiito  Tnffctimis  E\-nntlioin;ilii." 
=  H.  O.  Hall:     New  York  Modi.al  Itccoid,  November  11,  1890,  p.  698 

(643) 


644 


THE  INFECTIOUS  DISEASES. 


explainable,  does  it  not  suggest  the  possibility  of  infection  through   the 
gastro-intestinal  tract  as  perhaps  the  chief  source? 

Climate. — Ei)idemics  are  more  common  in  America  in  the  fall  and 
winter  than  in  the  summer  months,  although  1  have  seen  nuilignant  cases 
both  in  hospital  and  private  practice  just  as  Ijad  in  midsummer  as  in  mid- 
winter. We  know  by  clinical  experience  that  the  poison  of  scarlet  fever  is 
less  volatile  than  that  of  measles,  and  is  not  transmitted  any  great  distance 
through  the  atmosphere  (Hall). 

Table  No.  89. — Deaths  from  Scarlet  Fever,  in  Children  Under  15  years— Old  City 

of  New  York. 


Total. 

0               1 
Year.       Year. 

2 

Years. 

3 
Years. 

4 
Years. 

Under 
5Yrs. 

5-10 
Years. 

10-15 
Years. 

1890 

Males 
Females 

198 
201 

9          35 
14          40 

39 
42 

30 
36 

30 

24 

143 
156 

50 
39 

5 
6 

1891 

Males 
Females 

600 

588 

40 
26 

105 
95 

133 
124 

116 
106 

70 

72 

464 
423 

120 
155 

10 
10 

1892 

Males 
Females 

464 
469 

39 
29 

63 

74 

99 
105 

90 

77 

55 
53 

346 
388 

101 
116 

17 
15 

1893 

Males 
Females 

275 
258 

24 
23 

40 
40 

55 
54 

53 
43 

34 

30 

206 
190 

61 
62 

8 
6 

1894 

- 

Males 
Females 

252 

261 

17 
14 

50 
39 

50 
59 

42 
43 

35 
34 

194 
189 

50 
67 

8 
5 

1895 

Males 
Females 

241 
215 

16 
12 

34 

41 

72 

38 

50 
47 

27 
20 

199 
158 

36 
47 

6 
10 

1896 

Males 
Females 

201 
194 

8 
12 

34 

25 

54 
43 

32 

49 

20 
13 

148 
142 

53 

46 

6 

1897 

Males 
Females 

262 
231 

10 
15 

56 
33 

47 

46 

49 

48 

31 

30 

193 

172 

65 
54 

4 
5 

1898 

Male«i 

Females 

241 
265 

18 
18 

48 
40 

49 

54 

50 

57 

20 

40 

185 
209 

51 
52 

5 
4 

1899 

Males 
Females 

158 
169 

10 

8 

27 
32 

36 
34 

28 
31 

19 
16 

120 
121 

35 
39 

3 
9 

1900 

Males 
Females 

177 
122 

22 
6 

40 
22 

35 
26 

27 
14 

15 
22 

139 

90 

30 
25 

8 

7 

1901 

Males 
Females 

309 

297 

11 

18 

47 
39 

45 

47 

54 
43 

52 

48 

209 
195 

76 
88 

24 
14 

SCARLET    FEV^KK. 


645 


When  Contagious. — Eichhorst  says  it  is  least  contagious  during  the 
period  of  incubation,  most  pronounced  at  the  time  of  eruption,  and  with 
the  establishment  of  convalescence  and  advancing  desquamation  the  power 
of  contagion  steadily  diminishes.  The  average  duration  of  the  contagion 
is  six  weeks. 

Age. — The  greater  number  of  cases  occur  l)etween  the  ages  of  1  and  5 ; 
next  in  frequency,  5  to  15.    Then  the  frequency  gradually  diminishes. 

Stage  of  Incubation. — Authorities  differ  as  to  the  length  of  time  that 
usually  elapses  between  the  exposure  to  the  disease  and  the  disappearance 
of  symptoms.  The  usual  rule  is  from  a  few  days  to  a  week,  although 
(-■xceptions  will  extend  the  time  to  several  days  longer. 

Eichliorst  and  Yon  Leube  give  it  from  four  to  seven  days.  Individual 
susceptibility  plays  an  important  part  in  scarlet  fever  as  well  as  we  have 
seen  in  other  diseases. 

Henoch  maintains  that  we  cannot  form  an  idea  of  the  severity  or 
mildness  of  an  attack  by  the  early  symptoms. 


Table  No.    90. — Statistics  of  Cases  of  Scarlet  Fever  Treated  in  the 
Riverside  Hospital,  New  York  City. 


Yer. 

Number  of              T)Paths          '       Mortality 
Cases.                  iJeatns.        ,       percent. 

1903 

1904,  Jan.  to  Oct. 

835 

718 

76                    9.1 
46          1          6.4 

Bacteriology. — The  distinct  specific  cause  of  scarlet  fever  is  unknown, 
in  spite  of  immense  scientific  work.  A  specific  micro-organism  first  de- 
scribed by  Class^  is  a  non-capsulated  diplococcus,  appearing  occasionally  in 
streptococcic  form,  polymorphous  in  character.  It  is  constantly  found  in 
the  pharynx  in  scarbitinal  angina. 

Baginsky  and  Sommerfeld-  found  a  sireptodiplococcua  in  the  pharynx 
and  blood  in  scarlet  fever,  which  they  believe  to  be  the  etiological  factor  in 
that  disease.  As  yet  scarlet  fever  cannot  be  reproduced  in  animals,  and 
lience  this  microbe  must  be  looked  upon  as  the  probable  causative  factor. 
Owing  to  the  immense  amount  of  research  work  being  done,  the  day  is  not 
far  distant  wlien  the  specific  factor  of  all  infectious  diseases  will  be  dis- 
covered. 

Antitoxic  Substances  from  the  Blood  of  Convalescing  Cases  of  Scar- 
let Fever.  Measles.  Pneumonia,  and  Diphtheria.  —  0.  Huber  and  F. 
Rlumenthal"  succeeded  in  deriving  from  tlie  blood  of  convalescent  cases  in 


'  New  York  Medical  Record,  Seplcinber,  l.S!)9,  p.  3.S0. 

==  Berlin  Klin.  Woch.,  No.  22,  1900,  p.  588. 

*  Paper  read  before  Charite  Aerzte,  of  Berlin,  July^  1897. 


646  THE  INFECTIOUS  DISEASES. 

above  diseases  specific  antitoxic  suhstunces  in  solution.  Used  in  treatment 
of  scarlet  fever  they  found  that  the  disease  was  shortened,  the  severity 
lessened;  although  they  state  they  have  not  discovered  a  healing  serum, 
they  believe  that  they  will  be  able  to  isolate  therapeutic  antitoxic  sub- 
stances possessing  curative  properties. 

Leiicocytosis  in  Scarlet  Fever. — Dr.  J.  M.  Bowie^  gives  a  comprehen- 
sive review  of  the  subject,  ami  cites  the  results  of  the  examination  of  107 
cases  with  a  total  number  of  714  counts.  Of  these  77  were  ditferential  to 
determine  the  relative  jicrcentage  of  the  three  main  varieties  of  leucocytes. 
The  following  is  the  summary  of  his  conclusions : — 

1.  Practically  all  cases  of  scarlet  fever  show  leucocytosis. 

2.  The  leucocytosis  begins  in  the  incubation  period,  very  shortly  after 
infection ;  reaches  its  maximum  at  or  shortly  after  the  height  or  severity  of 
the  disease,  and  then  gradually  sinks  to  normal. 

3.  In  simple,  uncomplicated  cases  the  maximum  is  reached  during  the 
first  week,  and  the  normal  generally  some  time  during  the  first  three  weeks. 

4.  The  moje  severe  the  case  the  higher  is  the  leucocytosis,  and  the 
longer  it  lasts;  the  slighter  the  case  the  slighter  the  leucocytosis,  and  the 
shorter  time  it  lasts. 

5.  A  favorable  case  of  any  variety  of  the  disease  has  always  a  higher 
leucocytosis  than  an  unfavorable  one  of  the  same  variety. 

6.  The  temperature  has  no  effect  on  the  leucocytosis. 

7.  The  polymorphonuclear  leucocytes  are  increased  relatively  and  abso- 
lutely at  first,  and  then  fall  to  the  normal,  the  lymphocytes  acting  inversely 
to  this.     This  cycle  of  events  occurs  in  simple  cases  within  three  weeks. 

8.  Eosinophiles  are  diminished  at  the  onset  of  the  fever.  They  in- 
crease rapidly  in  simple  favorable  cases  till  the  height  of  the  disease  is  past, 
then  diminish,  and  finally  reach  the  normal  some  time  after  the  sum  total 
leucocytosis  has  disappeared — in  short,  when  the  poison  has  all  been  elimi- 
nated. 

9.  The  more  severe  the  case  the  longer  are  the  eosinopliiles  subnormal 
before  they  rise  again.  In  fatal  cases  they  never  rise,  but  sink  rapidly 
toward  zero. 

10.  The  leucocytes,  in  complications,  go  through  a  cycle  of  events 
similar  in  all  respects  to  that  of  the  primary  fever  as  regards  both  sum  total 
and  differential  leucocytosis,  and  the  same  laws  govern  the  behavior  of  the 
leucocytes  in  both  cases. 

In  regard  to  the  diagnosis  of  scarlet  fever,  the  simple  counting  of  the 
leucocytes  gives  little  aid.  A  differential  count,  however,  may  be  of  aid, 
for  scarlet  fever  is  one  of  the  few  acute  infectious  diseases  where  one  finds 


^Reported  in  Berlin  Klin.  Wochenschrift.      (No.  31,  1897.) 


SCARLET    FEVER.  647 

an  increase  in  the  eosinophiles  early  in  the  disease  and  the  persistence  of 
that  increase  for  some  time. 

With  regard  to  prognosis,  the  examination  of  the  leucocytes  seems 
likely  to  be  of  some  practical  value.  In  scarlatina  simplex,  if  the  case  be 
severe,  and  the  leucocytosis  be  high  and  rising,  one  may  predict  a  favorable 
course ;  and  conversely,  if  it  be  low  and  stationary,  one  may  expect  a  tedious 
case.  Regarding  the  differential  count,  if  the  eosinophiles  show  a  relative 
increase,  the  augury  is  good ;  if  they  are  normal  or  subnormal  after  the  first 
day  or  two,  then  the  case  will  in  all  probability  be  a  severe  one.  Further- 
more, as  long  as  a  relative  increase  of  eosinophiles  is  present  one  cannot  be 
sure  that  some  complication  will  not  ensue;  whereas,  if  the  eosinophiles 
have  come  down  to  normal  in  the  usual  wa}^,  one  may  be  free  from  anxiety 
in  this  respect. 

Pathology. — The  gross  and  histological  lesions  found  post-mortem  in 
scarlet  fever  depend  essentially  upon  two  processes :  first,  the  action  of  the 
scarlatinal  toxin,  associated  with  the  changes  seen  in  any  acute  febrile  dis- 
ease; and,  secondly,  they  may  occur  as  a  result  of  a  mixed  infection  due 
to  entrance  into  the  organism  of  the  streptococcus  pyogenes,  the  staphylo- 
coccus pyogenes  aureus  or  albus,  the  pneumococcus,  and  rarely,  other  micro- 
organisms. So  long  as  the  specific  agent  concerned  in  the  scarlatinal  infec- 
tion remains  obscure,  it  must  be  impossible — in  many  instances,  at  least — 
to  determine,  in  a  given  case,  which  of  these  two  elements  is  the  predomi- 
nant one.  In  cases  succumbing  early  in  their  course  to  the  intensity  of  the 
poison,  before  the  development  of  secondary  infections,  we  must  assume 
the  changes  present  to  be  due  to  the  specific  scarlatinal  virus,  while  in  those 
which  prove  fatal  later,  associated  with  grave  throat  lesions,  streptococcic 
angina,  etc.,  the  possibility  of  an  added  etiological  element  in  the  lesions 
present  after  death  must  be  admitted  (Corlett). 

Symptoms. — The  onset  is  usually  very  sudden.  In  young  children  the 
attack  is  preceded  by  a  convulsion.     Vomiting  is  an  early  symptom. 

Tongue. — The  tongue  has  a  whitish  fur  and  the  papilla?  will  be  found 
elevated  and  very  red.  It  has  the  so-called  '^strawberry"  appearance  (see 
colored  plate).  The  throat,  especially  the  tonsils,  will  be  found  intensely 
congested  and  dry.  Sometimes  a  severe  diarrhcea  is  the  first  symptom. 
'J'he  pulse  is  full  and  rapid,  from  120  to  140  beats  per  minute.  The  tem- 
])erature  on  the  first  or  second  day  is  about  102°  F.,  rarely  higher. 

Glands. — Enlarged  inguinal  glands  are  a  characteristic  feature  of  this 
disease.  Tiie  submaxillary  lymphatic  glands  at  the  angle  of  the  jaw  are 
swollen  and  tender  on  palpation.  The  mucous  membrane  of  the  mouth  is 
reddened.  The  j)h!U'ynx,  tonsils,  and  the  uvula  are  injected.  Monti^  calls 
attention  to  an  enantheiii  in  scarlet  fever  which  is  seen  h^te  on  the  first  day 


1  Jaliib.   f.   Kiiulli.,  vol.  vii,   p. 


(US  TlIK   IXFECTrin'S  DTSEASKS. 

or  early  on  the  second.  It  is  a  (lilTiiscd,  mottled  reddening  wliieli  begins 
upon  tlie  uvula,  spreads  (piickly  over  Die  hard  and  soft  palate,  covering  the 
|)illars  of  the  fauces,  and  finally  the  mucous  membrane  of  the  cheeks.  It 
does  not  as  a  rule  extend  to  the  post-pharyngeal  wall. 

The  Urine. — There  is  febrile  albuminuria  present,  which  disappears 
as  the  temperature  declines.    The  urine  is  scanty  and  high-colored. 


Fij;.  201. — Desquamation  of  the  Left  Side  of  the  Chest  in  a  case  of 
Scarlet  Fever.  Photographed  from  a  case  in  the  Riverside  Hospital. 
(Original.) 

The  Rash. — This  ap])ears  usually  within  the  first  twenty-four  hours. 
It  is  first  seen  upon  the  neck  and  chest — less  often  upon  the  small  of  the 
back.  It  is  a  bright  scarlet  pin-point  flush,  and  occupies  the  sites  of  the 
hair  follicles.  The  rash  extends  from  above  downward,  spreading  in  a  few 
hours  to  the  arms;  usually  in  twenty-four  hours  it  reaches  the  trunk,  legs, 
and  abdomen.     (Study  frontispiece.)     A  point  to  note  is  that  in  contrast 


PLATE  XVIII 


strawberry  Tonpriie  in  Scarlet  Fever.     Painted  from  a  case  in  the  Riverside 
Hospital.     The  body  rash  is  shown  in  the  Frontispiece.      (Original.) 


Beefy  Tongue  in  Scarlet  Fever.  The  tongue  bus  a  glazed  appearance. 
The  papillae  are  enlarged.  This  type  is  usually  seen  when  de.sqiianiation 
begins,  after  the  rash  has  faded.  Tainted  at  tlie  bedside  from  a  case  iu  the 
Riverside  Hospital.     (Original.) 


SCARLET    FEVER.  649 

to  measles  and  smallpox  it  is  much  less  marked  upon  the  face  and  cheeks. 
The  immediate  neighborhood  of  the  nose  and  mouth  remain  free  from  the 
eruption  and  have  a  peculiar  pallor,  a  marked  contrast  to  the  parts  affected 
by  the  eruption.  The  dorsal  surfaces  of  the  hands  and  feet  show  the  erup- 
tion. The  palmar  and  plantar  surfaces,  though  frequently  injected,  do  not 
usually  show  the  true  punctate  scarlatina  rash. 

The  rash  shows  great  variations.  While  it  may  show  large  or  small 
faintly  scarlet  colored  patches  lasting  but  a  short  time,  the  opposite  more 
frequently  occurs.  When  it  is  diffuse  it  may  be  of  an  intense  scarlet  or 
almost  purple  ccilor.  (See  frontispiece.)  It  frequently  shows  a  tendency 
to  stain  the  tissues  and  minute  hgemorrhages  may  occur  with  the  formation 
of  petechias.  The  symptoms  above  described  increase  in  severity  so  that 
the  clinical  picture  of  a  grave  septicaemia  is  apparent.  An  improvement 
in  cases  which  recover  should  not  be  expected  in  the  evening.  The  pharyn- 
geal symptoms  of  ulceration  show  improvement  and  the  lymphatic  glands 
are  less  swollen.  The  urine,  which  has  heretofore  been  diminished  in  quan- 
tity, becomes  more  abundant. 

Desquamation. — The  desquamation  of  the  skin  in  scarlatina  begins 
over  those  areas  on  which  the  rash  was  first  seen,  namely,  the  thorax  and 
neck.  Thus  we  will  frequently  find  evidences  of  desquamation  on  one  part 
while  another  part  of  the  bod}^  has  distinct  traces  of  the  rash. 

Character  of  tJie  Desquamation. — On  the  neck,  face,  and  trunk  the 
epidermis  peels  off  in  fine,  flaky  scales.  This  is  known  as  desquamatio 
furfuracea.  This  is  similar  to  the  desquamation  found  in  measles.  The 
extremities,  a1)0ut  the  hands  and  feet,  show  the  characteristic  desquamation. 
The  epidermis  peels  off  or  can  l)e  stripped  off  in  shreds  of  varying  lengths. 
This  is  known  as  desquamatio  niemhranacea  or  lameUosa.  Corlett  mentions 
an  instance  of  a  cast  of  a  finger  and  of  a  hand  being  peeled  off  during  des- 
quamation. 

Duration  of  Desquaination. — This  varies  greatly  and  is  influenced  by 
the  severity  of  the  infection  and  the  intensity  of  the  eruption.  It  persists 
longest  where  the  epidermis  is  thick,  namely,  about  the  hands  and  feet.  As 
long  as  a  single  ftal-e  of  necrotic  sliin  remains,  the  patient  may  he  a  source 
of  contagion. 

l-he  length  of  time  for  complete  desquamation  may  be  from  six  to 
eight  weeks.  It  may  be  of  a  shorter  or  longer  duration,  llepeated  des- 
quamation is  not  uncommon,  so  that  we  can  say  there  is  secondary  and,  less 
frequently,  tertiary  desquamation. 

Vahif.ties. 

Toxic  Scarlet  Fever. — This  is  the  most  malignant  form  and  is  very 
rare.  The  disease  is  very  abrupt  in  its  onset.  The  temperature  reaches 
105°  to  107°  F.,  and  sometimes  higher,  within  the  first  few  hours, 


650 


THE  INFECTIOUS  DISEASES. 


The  pulse  is  greatly  accelerated  and  is  weak  and  intermittent.  The 
cheeks  and  lips  are  blanched  and  may  show  cyanosis  very  early.  The  urine 
is  scanty,  high-colored,  and  albuminous,  or  may  be  completely  suppressed. 
There  are  marked  cerebral  disturbances,  such  as  convulsions  and  active 
delirium.  Frequently  we  have  marked  dyspnoea,  the  respiratory  rhythm 
being  short  and  quick,  due  usually  not  to  any  change  in  the  lungs  at  this 
time,  but  probably  to  irritation  of  the  respiratory  centers,  according  to 
Ausset.  Ataxic  and  adynamic  forms  are  characterized  by  early  and  pro- 
found constitutional  depression,  due  to  the  effect  of  the  toxin  on  the  nerve 
centers,  the  symptoms  rapidly  assuming  a  typhoidal  type. 

In  the  liasmorrhagic  forms  the  exanthem  acquires  a  dark  purplish  hue. 
Small  petechias,  varying  in  size  from  a  pin-head  to  a  lentil,  appear  scat- 
tered irregularly  over  the  body.    The  blood  oozes  from  the  gums,  the  sputum 


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Ficr.  202. — Septic  Scarlet  Fever  with  Myocarditis,  Suppurative  Arthritis, 
Double  Purulent  Otitis,  General  Pyaemia.  Ca,se  seen  in  consultation  in 
private  practice.      Child  4  years  old.      (Original.) 


even  being  tinged  witli  it,  while  epistaxis  may  l:»e  severe.  Blood  may  be 
discharged  from  the  l)owc]s  or  tlie  stools  may  l)c  tarry  in  color. 

Bleeding  is  frequently  seen  from  the  genito-urinary  tract  or  the  urine 
shows  the  presence  of  blood.  This  form  of  disease  is  usually  encountered  in 
very  feeble  infants  under  2  years  of  age  and  is  invariably  fatal. 

Septic  Scarlet  Fever. — This  type  is  most  commonly  met  with  in  chil- 
dren. The  symptoms  are  of  a  more  severe  type.  There  is  high  and  con- 
tinued fever,  with  involvement  of  the  pharynx  and  tonsils.  Prostration  is 
the  vital  symptom  showing  the  evidence  of  severer  infection.  There  are 
marked  cerebral  symptoms,  such  as  extreme  restlessness,  convulsions,  or  mild 


SCARLET  FEVER.  651 

delirium.  In  this  type  we  usually  have  persistent  vomiting  associated  with 
general  apathy.  The  fever  rises  suddenly  to  105°  F.  or  40.5°  C,  or  higher. 
The  pulse  becomes  very  small  and  rapid,  from  1-10  to  IGO  per  minute,  al- 
though at  times  200  per  minute.  Tlie  thirst  is  extreme;  the  mouth  being 
dry  and  gums  parched.  The  throat,  especially  the  tonsil,  is  deeply  injected 
and  frequently  has  scattered  foci  of  exudate  on  the  surfaces.  The  urine  is 
concentrated,  and  invariably  contains  albumin. 

Scarlatina  Sine  Exanthemata. — Cases  frequently  occur  in  which  every 
evidence  ot  scarlet  fever  exists,  but  there  is  no  eruption.  Henoch  states 
that  he  believes  the  eruption  is  always  preseut  and  thinks  that  it  is  occa- 
sionally overlooked.  The  eruption  is  frequently  of  such  an  evanescent  char- 
acter that  it  entirely  escapes  notice,  but  a  subsequent  desquamation  and 
nephritis  will  usually  strengthen  the  diagnosis. 

A  case  of  scarlatina  sine  exanthemata  was  seen  by  me  in  tlie  family  of  Dr.  J. 
Lurie,  of  New  York  City.  A  child  about  Jf  i/ears  old  liad  been  in  apparent  health. 
There  was  no  history  of  vomiting  nor  any  gastric  disturbances.  No  history  of  ex- 
jjosure  to  scarlet  fever.  When  examined  by  me  I  found  no  evidences  of  scarlet 
fever.  The  throat  was  somewhat  congested,  but  had  no  patches,  nor  was  there  any 
evidences  of  necrotic  membrane  visible  in  any  portion  of  the  throat.  The  lymphatic 
glands  of  the  neck  were  not  enlarged.  The  urine  was  very  scanty  and  contained 
more  than  50  per  cent,  hy  volume  of  albumin.  Blood  was  also  present  in  large 
quantity.  There  were  also  hyaline,  epithelial  and  gi'anular  casts  present,  when  a 
drop  was  examined  under  the  microscope. 

Tlie  child's  urine  was  greatly  diminished  in  quantity,  hardly  a  tablespoonful 
being  passed  at  one  sitting.  Dim-etin  and  citrate  of  potash  acted  very  well  as 
diuretics,  and  later  the  secretion  of  urine  was  normal  in  both  quality  and  quantity. 
At  times  it  seemed  as  though  the  urine  consisted  of  pure  blood.  Later  the  child 
developed  an  otitis  media — which  was  preceded  by  a  rise  in  temperatitre.  The  child 
made  a  good  convalescence  and  is  perfectly  icell  to-day. 

It  may  be  of  interest  to  note  that  the  child  was  fed  exclusively  by  the  2>ercent- 
age  method  at  the  Walker-Gordon  Laboratory. 

Scarlatina  Papulosa. — Small  slightly  elevated  papules  of  a  dark-red 
color  develop  at  the  site  of  the  hair  follicles.  They  are  more  readily  de- 
tected by  the  finger  than  by  the  eye,  and  are  observed  twelve  to  eighteen 
hours  before  the  ordinary  scarlatinal  rash  appears. 

Scarlatina  Variegata. — This  form  is  marked  by  an  extremely  irregular 
distril)ution  of  the  eruption,  frequently  associated  with  the  development  of 
well-defined  macular  areas  of  an  intense  red  color,  situated  at  the  site  of  the 
hair  follicles,  and  in  many  instances  simulating  the  exanthem  of  measles. 

Scarlatina  Sine  Febre. — Among  extremely  mild  eases  of  scarlatina  in- 
stances are  frequently  seen  in  which  ofter  a  slight  initial  rise,  the  disease 
progresses  without  any  subsequent  elevation  of  temperature  above  98.5°  to 
99°  F.,  every  other  symptom  being  present,  but  in  a  mild  degree. 

Henoch  reports  4  cases  out  nf  1~5  with  irregularities  of  temperature. 


652  1'HE  INFKCTlurS  DISEASES. 

Fever  of  an  inverted  iype  has  been  reported  by  Henoch,  who  noted  the  tein- 
pv3rature  curve  quite  the  reverse  of  normal,  in  which  the  temperature  was 
higher  in  tlie  morning  than  in  the  evening. 

Scarlatina  Sine  Angina. — This  form  of  scarlatina  has  very  slight  tliroat 
symptoms  or  so  insignificant  as  to  appear  almost  absent.  A  slight  conges- 
tion of  the  throat  is  visible,  and  usually  a  faint  enanthem  is  present  early 
in  the  disease. 

The  tonsils  are  not  enlarged,  but  there  is  an  almost  constant  enl(ir(/e- 
ntent  of  the  papiUce  at  the  tip  and  edges  of  the  tongue — an  iniportant  d'uuj- 
nostic  aid. 

Complications.^ — Scarlatina  ivith  Other  Exanthemata:  Mixed  infec- 
tions are  frequently  noted.  Measles,  chicken-pox,  or  smallpox  are  met  with. 
Corlett  depicts  a  case  of  scarlatina  with  chicken-pox. 

I  have  seen  a  case  of  scarlet  fever  complicated  with  measles,  in  private 
practice,  in  consultation  with  Dr.  Harry  Weinstein,  of  New  York  City. 
]\Iixed  infections  have  been  seen  many  times  during  my  service  in  the  scarlet 
fever  wards  .of  the  Riverside  Hospital — scarlet  fever  and  whooping-cougli. 
scarlet  fever  and  measles  very  often,  scarlet  fever  and  diphtheria  as  well. 

The  Throat. — Scarlatina  is  usually  seen  very  early  in  the  pharynx  and 
fauces.  This  takes  place  whether  we  are  dealing  with  a  mild  or  severe  in- 
fection. We  know  that  certain  pathogenic  bacteria,  such  as  streptococci,  are 
invariably  found  during  the  course  of  scarlatina. - 

]\Ianv  bacteriologists  agree  that  the  Klebs-Loeffler  bacillus  is  usually 
absent,  though  there  are  many  cases  of  true  diphtheria  complicating  scarlet 
fever.  Several  cases  of  diphtheritic  angina  have  been  seen  by  me  while  on 
service  at  the  scarlet  fever  wards  of  the  Riverside  Hospital.  Lemoine  found 
the  streptococcus  pyogenes  in  93  cases  out  of  117  studied  by  him.  The 
Klebs-Loeffler  bacillus  was  found  in  addition  in  5  cases  of  this  series,  and 
the  bacillus  coli  communis  in  9  cases. 

Angina  Pseudonienilranosa  (of  Streptococcic  Origin). — False  mem-. 
i)ranes  upon  the  tonsils  or  pharynx  are  seen  in  the  severe  and  septic  types 
of  this  disease.  It  is  simply  a  necrotic  infianimatory  deposit.  On  the  second 
(lay  the  mucous  membrane  of  the  pharynx  is  intensely  reddened  and  con- 
gested. The  tonsils,  which  are  mucli  inflamed  and  swollen,  show  scattered, 
irregular  patches  of  gray  or  grayish  white  exudate,  completely  occluding  the 
tonsillar  crypts  over  a  more  or  less  limited  surface.  One  or  both  tonsils 
may  be  affected.  In  many  instances  the  ])haryngeal  inflammation  from  the 
beginning  shows  an  extreme  grade  of  intensity.     This  may  spread  over  the 


'  "Vulvo-vaginitis  Follow! ii.<,'  Scjirlct  Fever"  is  deseribod  on  ])age  40:^  (cliapicr 
on  "Vulvo-vaginitiw"). 

^  See  elaborate  clinical  and  bacteriological  studies  made  by  Baginsky  and 
Sommerfeld,  in  Arcliiv.  fiir  Kiudcilicilkiinde.  1000,  and  Beilin.  Klin.  Woch.,  No.  22, 
IPOO,  p.  588. 


SCARLET  FEVER. 


653 


posterior  pharyngeal 
wall,  the  hard  pal- 
ale,  and  the  luacous 
membrane  oi'  the  pos- 
terior surfaee  of  the 
cheek;  also,  to  the 
posterior  nares  and 
the  Eustachian  tube, 
with  resulting  exten- 
sion of  the  inflam- 
matory process  to  the 
middle  ear.  There 
is  a  very  foul  odor  to 
the  hreath,  and  usu- 
ally a  thin  acrid  se- 
cretion from  the  nos- 
trils, causing  excor- 
iation, fissures,  and, 
rarely,  rhagades. 

The  nostrils  may 
be  occluded  and  the 
mouth  held  open  in 
an  attempt  to  breathe. 

Angina  Scarla- 
tina Menibranosa  (of 
True  Diphtheritic 
Origin).  —  This 
should  be  regarded 
as  a  true  diphtheritic 
complication  and 
treated  as  diphtheria 
(see  chapter  on 
"Diphtheria"). 

0/j7u-.  —  The 
extension  of  the  in- 
fection from  the  pha- 
rynx tlirough  the 
Eustachian  tubes  has 
already  been  mentioned.  As  a  rule  the  younger  the  child,  the  greater  the 
danger  of  otitis.  According  to  Bader  and  Guinon,  the  mild  or  catarrhal 
form  occurs  in  33  per  cent,  of  all  cases  of  scarlet  fever,  and  the  purulent 
form  is  less  common,  occurring  in  4.5  per  cent,  of  all  cases. 


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654  THE  IXFECTlorS  DISEASES. 

Caiger,  reporting  4015  cases  of  scarlet  fever,  noted  ear  discharge  in 
11.05  per  cent.  In  a  scries  of  31)7  cases  observed  by  me,  including  severe, 
malignant,  and  ail  complicated  varieties,  there  were  8.^  middle  ear  dis- 
charges, 68  purulent,  and  14  catarrhal. 

About  20  per  cent,  of  all  cases  seen  l)y  me  had  middle  ear  trouble.  It 
is  imiwrtant  to  have  tlie  middle  car  examined  when  Jiigh.  fever  persists 
during  an  attack  of  scarlet  fever.  Persistent  Jtigh  fever  in  a  case  of  scarlet 
fever  occurred  in  my  private  practice.  It  was  also  seen  by  Dr.  J.  W. 
Brannan  and  by  Dr.  Dcncli.  After  an  examination  of  tJie  middle  ear,  a 
thorough  incisio7i  of  the  drum  membrane  liberated  pus  and  relieved  the 
temperature  for  a  time. 

The  hand  will  frequently  be  carried  to  the  head  or  ear.  The  neigh- 
boring lymphatic  glands  are  enlarged,  palpable,  and  may  be  tender.  After 
a  few  days,  unless  relieved  by  incision,  the  tympanic  membrane  ruptures 
spontaneously.  The  symptoms  then  usually  subside.  Wlien,  however,  the 
inflammation  becomes  purulent  (otitis  media  suppurativa),  then  the  con- 
dition is  serious,  owing  to  the  possibility  of  deafness  arising. 

Empyema  of  the  mastoid  antrum,^  resulting  from  chronic  suppurative 
otitis  media,  occurs  in  a  small  percentage  of  cases.  With  the  establishment 
of  a  communication  between  the  tympanic  cavity  and  the  cells  of  the  mas- 
toid, there  is  usually  a  slight  decrease  in  the  amount  of  discharge  from  the 
ear.  The  temperature  rises  to  104°  F.,  or  higher,  and  shows  a  marked 
fluctuation  of  a  remittent  character.  There  may  be  rigors.  If  old  enough 
the  child  will  complain  of  pain  in  the  mastoid  region  with  tenderness  ou 
palpation  over  the  mastoid  process. 

The  pulse  becomes  rapid  and  irregular.  These  symptoms  continue  from 
day  to  day,  and  unless  an  operation  is  performed  these  cases  will  end  fatally, 
due  to  the  development  of  meningitis. 

More  rarely  an  inflammatory  swelling  appears  behind  the  external 
ear — situated  over  the  mastoid — associated  with  a  rise  of  teuiperature,  local 
tenderness,  with  more  or  less  forward  projection  of  the  ear;  and  occasionally 
local  suppuration,  with  abscess  formation,  takes  i)lace. 

A  case  of  tliis  kind  occurred  in  the  private  practice  of  Dr.  R.  W.  Reid,  of  Now 
York  City,  with  whom  I  saw  the  case  in  consultation.  The  cliihl  had  a  very  severe 
attack  of  scarlet  fever.  It  was  of  a  septic  character.  Necrotic  nionibranes  could  be 
seen  over  the  pharynx  and  tonsils.  There  was  persistent  fever.  The  child  Avas 
decidedly  rachitic.  The  case  was  complicated  with  an  acute  nephritis.  The  urine 
was  very  scant  and  was  loaded  with  albumin  and  casts.  Later  the  right  ear  dis- 
charged pus  very  freely. 

When  I  saw  the  child  there  was  a  superficial  swelling  over  the  mas-toid  which 
pushed  the  ear  forward.     The  inflammatory  condition  was  local  and  due  either  to 


*  Read  article  on  mastoid  (chapter  Otitis)  page  857. 


SCARLET    FEVER.  655 

periostitis  or  to  a  local  adenitis,  remotely  dependent  on  the  middle  ear  suppuration. 
An  incision  made  liberated  a  large  quantity  of  pus.  The  child  died  of  general  septi- 
caemia following  toxic  nephritis. 

Angina  Ludovici  (Tippet  Neck). — This  may  occur  about  tlie  fifth  day 
of  the  disease,  though  more  commonly  seen  early  in  the  second  week  of  the 
attack. 

The  skin  is  indurated,  glossy,  and  may  pit  on  pressure,  though  it  may 
give  no  sense  of  fluctuation.  The  process  may  be  limited  to  the  angle  of 
the  jaw  or  involve  the  entire  neck;  it  may  extend  downward  to  the  clav- 
icles and  upward  along  the  sides  of  the  face  and  head,  rendering  the  head 
almost  if  not  wholly  rigid.  The  diffuse  cellulitis  of  the  deeper  tissues  con- 
stitutes one  of  the  gravest  complications  of  scarlet  fever,  proving  almost 
invariably  fatal.  Death  results  from  a  rupture  of  one  of  the  large  vessels, 
the  jugular  vein  or  internal  carotid  artery,  or,  as  a  result  of  thrombosis 
or  embolism,  with  fatal  meningitis  or  pyaemia.  The  greater  the  toxemia, 
the  more  pronounced  the  lymphatic  enlargement. 

Tlie  Lymph  Glands. — The  neighboring  glands  are  enlarged  and  tender 
on  palpation.  The  infiltration  of  the  glands  may  be  extreme,  and  in  rare 
instances  an  excessive  infiltration  of  the  cellular  tissue  of  the  neck  occurs, 
which  becomes  hard  and  indurated,  and  occasionally  renders  the  head  im- 
movable. 

Phlegmonous  Infanimaiion  of  tlie  Neck — Diffuse  Cellulitis.'^ — Scham- 
bcrg  studied  the  glands  in  100  cases  of  scarlatina.  He  found  the  maxillary 
glands  enlarged  in  95  per  cent,  and  the  submaxillary  glands  enlarged  in  30 
])er  cent,  of  Ins  cases.  Tlie  posterior  cervical  glands  were  found  enlarged 
in  77  per  cent,  of  the  cases.  Sometimes  the  parotid  glands  arc  also  in- 
volved. Frequently  the  inflammatory  condition  persists  and  suppuration 
occurs,  resulting  in  so-called  phlegmonous  inflammation.  Even  when  freely 
incised  tliere  is  danger  of  pus  I)urrowing  beneath  the  connective  tissue. 
Sometimes  a  rapid  and  diffuse  cellulitis  with  excessive  infiltration  of  tlie 
deeper  tissues  is  associated  with  the  su])purative  process. 

Retropharyngeal  abscess  occurs  occasionally.-  Bokai  found  (I  cases  out 
of  6G4  cases  of  scarlet  fever. 

Schamberg,  in  a  study  of  ihe  lymphatic  glands  in  scarlatina,  found  the 
various  grou[)s  enlarged  in  fhe  following  proportion  in  100  cases: — 

Inguinal   glands    100  per  cent. 

Axillary    0(5  per  cent. 

Maxillary    95  per  cent. 

Posterior  cervical  77  per  cent. 


'^  Scliamberg :  Annals  of  (iyniecol.  and  Podiatry,  December,  ISS!),  vol.  viii,  p.  .'?9. 
^  Jahrbuch  f.  Kinderheilkunde,  vol.  x,  p.  108. 


656  I'ui'^  iNFECTiors  diseases. 

Anterior  cenioal    44  per  cent. 

Subniaxilliuy 3G  per  cent. 

Ei)itr()clilcar    "ili  per  cent. 

Sublingual    2.')  per  cent. 

As  a  rt'sult  of  tlie  analysis  of  these  100  cases  he  linds  that  the  inaxillarv 
glands  coinnionly  attain  the  largest  size,  and  also  most  frequently  itndergo 
suppuration.  In  all  eases  exaniinetl  on  the  second  and  third  (hiy  of  the 
disease  the  enlargement  of  the  lymphatic  glands  was  well  marked. 

ScarlatinaJ  synuviiis  (so-called  scarlatinal  rheumatism  or  pseudorheu- 
matism)  is  occasionally  met  with.  Ashhy^  met  with  this  condition  in  'I  ])er 
cent,  of  his  cases. 

Hodge  found  synovitis  in  117  out  of  oOUO  cases  studied,  or  3. 2  per 
cent.     There  are  two  distinct  forms : — 

(a)   Simple  catarrhal  or  serous  synovitis. 

(h)   Suppurative  or  purulent  arthritis. 

The  streptococcus  pyogenes  has  been  found  in  both  forms  in  pure 
cttlture  and  combined  with  other  micro-organisms. 

This  complication  occurs  more  often  in  children  over  5,  and  is  rarely 
met  with  in  children  under  3,  according  to  Holt. 

The  symptoms  met  with  are :  Pains  in  the  affected  joints,  swelling, 
which  may  or  may  not  be  marked  with  slight  impairment  of  motion,  some 
redness,  and  a  slight  rise  in  temperature. 

Owing  to  an  effusion  of  serum,  large  joints,  such  as  the  knee  and 
shoulder,  remain  swollen  many  weeks.  When  suppuration  develops  in  the 
involved  joint,  Henoch  claims  that  it  is  due  to  emboli,  following  septi- 
caemia. 

The  Kidneys. — There  are  three  forms  of  involvement  of  the  kidne3^s  in 
scarlatina : — 

1.  Transient  febrile  albuminuria  and  the  interstitial  catarrhal  ne- 
phritis. 

2.  Septic  nephritis. 

3.  Post-scarlatinal  nephritis. 

Transient  albuminuria  occurs  in  three-fourths  of  all  eaBes  of  scarlet 
fever.  It  does  not  differ  from  a  "febrile  albuminuria"  seen  in  all  acute 
infectious  diseases  associated  with  high  temperatures.  It  has  no  special 
significance. 

CatarrJial  nephritis  not  infrequently  occurs  in  the  fiirst  week  in  cases 
of  moderate  severity.  The  urine  contains,  besides  albumin,  degenerated 
epithelial  cells,  mucous  cylindroids,  and  rarely  epithelial  or  even  hyaline 
casts,  occasionally  a  few  red  and  white  corpuscles. 


^British  Medical  Journal,  1SS3,  vol.  ii,  p.  514. 


{SCAJILET   FEVER. 


657 


Clinically,  we  have  slight  evidence  of  oedema.  Pathological  changes 
frequently  take  place  without  a  trace  of  allnirnin  or  without  the  presence  of 
casts.     Such  cases  have  been  reported.^ 

Septic  Xc [ill  n't  is. — Where  the  scarlatinal  virus  causes  a  general  tox- 
jBmia,  and  we  have  grave  throat  symptoms  accompanied  l)y  necrotic  de- 
posits on  the  tonsils  and  pharynx,  there  are  always  swollen  glands.  N"e- 
phritis  develops  from  the  intensity  of  the  infection  caused  mainly  by  the 
streptococcus  pyogenes.  In  many  instances  death  occurs  before  well-de- 
fined symptoms  of  nephritis  are  made  out.  In  such  cases  there  is  no 
dropsy  and  ursemic  symptoms  are  aljsent.  In  rare  instances  the  urine  is 
normal  during  the  entire  attack  until  a  post-mortem  shows  the  existence 
of  nephritis. 


-r  T  T  T -r  T  T  T  "T"  T -r -r  T  T 

<MfO       ^      to      <D      t-       COO)       2       =N21iO 

HUUrv      a.  <  0.  <i -^  ci.  <■  s: -"lla:  •<  <5  c| «)  ^  <1<  p;  "!  fc  <:      <t      <      < 

<ii;      a.  -^a:  <sii^-<      <;(i;-5a;<;tt,-flp.-<ta.-<;a.ti0.^a;<!a. 

UJ 

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o 
LU 

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UJ 

z. 

UJ 

105                   1 

f                                     ^'                            -i'l 

10^           Ji             T 

V               i\              -A' 

103                 5 

'A  L-^- iv-ii. 

10^               li 

...L_.___L .[.:._L  JJ- 

101 X,     Is         1 

L    Lj_-^L]j  1 

lOD       \    7      .1 

n\,  ...l....-.^A 

199                       \         -, 

'    \  I 

NOMI\  t \r"  \^ ^-"i  —  ?- 

\ _L_____ 

R 

11    %_l\\l-\\\\lt\t'il\\'Al\l\'i\ 

"RESF  ?:?5a?;?ij?;?.f5  =  ?;?i2?is3:?552s    2    ?.    ?.    2 

8^     ?i3;3?;23?2Sg5iSSj*S?.SSS  =  SS"S 

Fig.  204. — Septic  Nephritis  fi'om  Riverside  Hospital. 

Post-scarlatinal  Nephritis. — When  tlie  acute  symptoms  subside  and 
nephritis  develops  it  is  called  post-scarlatinal  nephritis.  This  nephritis  is 
uot  always  glomerular.  Jurgensen's  statement  that  the  effect  of  the  in- 
flammatory irritant  depends  not  only  upon  its  virulence  (toxicity),  but 
upon  the  length  of  time  during  which  it  acts  upon  a  given  local  site,  is 
ixtremely  interesting  and  important. 

Symptoms. — The  symptoms  may  l)e  sudden,  although  if  daily  exami- 
nations of  tlie  urine  are  made,  a  gradual  diminution  in  the  (juantity  se- 
creted in  twenty -four  hours  will  be  noted. 

The  child  Avho  has  seemed  apparently  well  and  convalescing  becomes 
pale,  is  restless  and  irritable,  and  if  old  enough,  complains  of  headaches, 


Corlett : 


"Treatise  of  Infectious  Exanthemata/'  p.  201. 

42 


658 


THE  INFECTIOUS  DISEASES. 


thirst,  and  loss  of  appetite.     (Constipation  may  be  present.     Vomiting  is  '' 
usually  an  early  symptom  of  nephritis. 

The  earliest  symptoms  of  nephritis  are :  rise  of  temperature,  occur- 
rence of  oedema,  however  slight,  involving  particularly  the  lower  eyelids, 
with  distinct  puffiness  of  the  eyes.  Sometimes  the  whole  face  is  swollen 
and  bloated.  The  feet  and  legs  are  oederaatons,  so  also  the  scrotum  and 
penis  in  the  male,  and  the  labia  majora  in  the  female.  Such  oedema  may 
also  be  seen  on  the  dorsum  of  the  feet  and  upon  the  knuckles.  There  is 
pitting  on  pressure. 

BOUND  EPITHELIAL  CELLS         red  bLOOD  CORPUSCLES 
PROB.\BLY  FROM  Ct)NVOLUTED  \    \ 

TUBULES  ,   , f--r~~^  ^EPITHEUAL  AND 

vJPUS  CAST 

/x 


EPITHELIAL 

CELL 
PROBABLY  FROM 
VAGINA 


GRANTJLAK, 

cast: 


HYALINE  CAST 


PUS  CORPUSCLES 
Fig.  205. — Drop  of  I'rine  from  a  Case  of  Post-scarlatinal  Nephritis.     Original 
drawing  from  a  child  seen  in  consultation  by  the  Author. 

The  urine  is  greatly  diminished  in  quantity,  so  that  several  tcaspoonfuls 
only  may  be  passed  in  twenty-four  hours.  The  reaction  is  acid.  Specific 
gravity  is  from  1.006  to  1.065,  the  latter  being  rare.  The  amount  of  urea 
is  under  3  per  cent.  Albumin  is  present  from  0.5  to  1  per  cent,  and 
higher.    The  diazo  reaction  is  of  no  value  in  scarlet  fever. 

Microscopically. — There  may  be  present  hyaline,  epithelial,  granular 
and  blood  casts,  fragmented  renal  epithelium,  white  and  red  blood-corjjus- 
cles;  the  latter  in  varying  numbers;  uric  acid  and  oxalic  acid  in  crystal- 
line and  amorphous  form,  and  more  or  less  granular  debris. 

Cases  are  seen  now  and  then  in  which  almost  normal  conditions  of  the 
urine  prevail  and  still  nephritis  exists. 

Nephritis  usually  exists  a  few  weeks,  although  obstinate  caso^s  may 
continue  for  months  and  even  years. 


SCARLET  FEVER. 


659 


Great  care  sJionld  he  exercised  in  giving  the  prognosis  in  cases  of  post- 
scarlatinal nei^liritis.  Lraiiuia,  when  oceurriug  dui-iug  nei^hritis,  is  a  grave 
symptom.  It  is  usually  preceded  by  vomiting,  stupor,  and  peculiar  twitch- 
in  gs  of  the  facial  muscles. 

The  pulse  is  slow;  the  temperature  subnormal;  the  tongue  is  dry. 
Sometimes  just  the  reverse  exists  and  there  is  high  fever,  very  frequent 
and  small  pulse;  the  respirations  are  short  and  hurried,  and  the  skin  is 
dry. 


Fig.  200.— The  Heart  in  a  Case  of  Scarlet  Fever:  a.  a.,  Parasternal  line. 
b.  h.,  Mammary  line,  c,  Apex.  x.  op.  x.  x.,  Location  of  murmur.  From 
Autlioi-'s  service  at  the  Riverside  Hospital. 


Convidsions  may  develop,  clonic  in  character,  of  varying  intensity,  in- 
volving the  face  and  extremities  as  a  whole.  Sometimes  only  distinct 
groups  of  muscles  are  involved.  Cyanosis  is  marked,  complete  suppression 
of  urine  follows,  coma  ensues,  and  usually  those  cases  end  fatally. 

Anasarca  is  frequently  associated  with  or  sul)sequent  to  oedema.  We 
frequently  have  serous  exudations  into  the  serous  cavities — pleura,  pericar- 
dium, or  peritoneum.  G^^dema  of  the  lungs,  sometimes  a?dema  of  the  larynx, 
results,  and  is  usually  fatal.  Mayr  mentions  oedema  of  the  pia  mater  and 
ventricles  of  the  brain. 

TliG  heart  requires  careful  watching  in  scarlet  fever.  Its  great  sus- 
ceptibility to  the  toxin  and  the  dan^jer  of  paralysis  should  be  remem])ered. 


660  'J'lii*^  rNFECTiors  diseases. 

The  heart-sounds  may  lose  tlicir  normal  tone,  the  first  sound  becoming  soft 
and  valvular,  or  they  may  run  together.     We  have  in  the  liegiunin*;-  tachy-4 
eardia  (increased  heart's  action),  later  bradycardia  (slowed  heart's  action). 
These  symptoms  jwint  to  an  existing  mild  myocarditis,  according  to  Koui- 
berg.^ 

In  some  cases  pericarditis  or  endocarditis  may  develop.  In  the  ma- 
jority of  cases  the  endocaril'mnt  of  the  heart  wall,  rather  than  the  valves,  is 
involved. 

The  Lungs. — In  addition  to  the  oedema  previously  mentioned,  bron- 
chitis frcijuently  accompanies  scarlet  fever.  Broncho-pneumonia  is  also 
frequently  noted.  Henoch  believes  l)ronchial  involvement  is  frequently 
overlooked.  It  is  no  doubt  duo  to  accidental  transmission  of  septic  nuite- 
rial  from  the  throat  into  the  trachea  and  lungs  (so-called  Schluck-pneu- 
monie). 

It  may  also  be  the  result  of  direct  infection  through  the  blood-vessels, 
a  part  of  the  general  sepsis. 

Acute  croupous  pneumonia  occurs  more  frequently  in  cases  in  which 
scarlatinal  nephritis  exists. 

Pleurw. — Scarlatinal  poison  seems  to  affect  the  serous  membranes  of 
the  body,  so  that  inflammation  of  the  pleura  is  by  no  means  rare.  It  is 
usually  seen  during  the  second  week  of  scarlet  fever  and  is  unilateral.  When 
excessive  exudation  exists  we  must  watch  the  case  carefully,  as  a  fatal  ter- 
mination is  by  no  means  rare.  Empyema  was  seen  by  me  as  a  complication 
of  scarlatina  at  the  Riverside  Hospital. 

Gastro-intestinal  Tract. — Early  in  the  disease,  through  infection,  very 
young  children  have  stomatitis — ulceration  of  the  mucous  membrane  of  the 
mouth  and  cheeks  seriously  interfering  with  nutrition.  Actual  gangrene 
can  occur.    See  chapter  on  "Noma,"  for  the  case  reported  by  me. 

Diarrhoea  and  vomiting  are  frequently  noted.  Both  are  early  symp- 
toms.    Diarrhoea  may  be : — 

(a)  A  simple  catarrhal  enteritis. 

(h)   Dysentery  with  bloody,  purulent  stools. 

(c)   Of  a  typhoidal  character — watery  stools  with  marked  tympanites. 

Liver. — Enlargement  of  the  liver  sometimes  occurs.  Sometimes  at- 
rophy has  been  noted.  Icterus  is  frequently  seen,  though  it  disappears  with 
convalescence.  Baginsky  maintains  that  when  icterus  exists  with  nephritis, 
it  is  to  be  dreaded  particularly  as  predisposing  to  the  danger  of  uraemia. 

General  furuncnJosis  or  multiple  abscesses  are  occasionally  seen.  They 
are  usually  met  with  in  children  with  severe  systemic  infections,  having  low 
vitality. 


"Ernst  Romberg:  "Ueber  die  Erkrankungen  des  Herzmuskels  bei  Typhus  Ab- 
dominalis,  Rcharlaeh,  imd  Diphtherie,"  Deutsch  Archiv.  fiir  klin.  Med.,  vol.  xlviii, 
1891,  pp.  369  et  seq. 


i 


SCARLET    FEVER.  661 

A  case  of  tliis  kind  was  seen  by  me  in  consultation  with  Dr.  Glass  of  New  York 
City,  in  which  a  child,  very  rachitic,  developed  multiple  abscesses  in  almost  every 
joint  in  the  body. 

iSuch  cases  invariably  end  fatally. 

The  spleen  is  frequently  enlarged  and  readily  jialpable  at  the  margin 
of  the  ribs.     In  some  cases  it  is  double  its  normal  size. 

Sequelae. — Tuberculosis  rarely  follows  scarlet  fever.  Frequently  pro- 
found ana?mia  is  seen.  Occasionally  true  diphtheria  follows,  leaving  chronic 
enlargement  of  the  tonsils  or  chronic  inflammatory  changes  in  the  pharyn- 
geal and  nasal  mucous  membrane. 

Forchheimer^  has  reported  persistent  ozsena  as  a  sequela  to  scarlet  fever. 
Total  deafness  or  partial  loss  of  hearing  is  one  of  the  most  common  sequelae 
of  this  disease. 

Chronic  nephritis  and  endocarditis,  with  resulting  permanent  lesion 
of  the  mitral  valves,  frequently  follow  scarlet  fever. 

Gangrene  of  Arms  and  Legs  After  Scarlet  Fever  and  Other  Infec- 
tious Diseases. — Eichhorst-  reports  the  case  of  a  -t-year-old  girl  who  had  an 
unusually  severe  attack  of  scarlet  fever.  At  the  end  of  the  third  week  signs 
of  embolism  of  the  popliteal  artery  suddenly  appeared  in  the  left  foot  and 
leg.  Gangrene  progressed  until  the  line  of  demarcation  was  sharply  ex- 
hibited above  the  lower  half  of  the  leg.  Amputation  was  performed  and 
the  child  made  a  good  recovery.  A  thrombus  was  found  in  the  left  popliteal 
artery  1  centimeter  above  its  bifurcation,  extending  into  both  the  anterior 
and  posterior  tibial  arteries  for  the  same  distance.  The  popliteal  artery 
showed  signs  of  endarteritis.  Pure  cultures  of  the  streptococcus  pyogenes 
were  found  in  the  pus  from  a  left-sided  otitis  media  and  from  an  abscess 
on  the  forehead. 

Only  two  other  cases  of  gangrene  following  scarlet  fever  are  reported 
in  medical  literature.  Both  lower  extremities  were  involved  in  these  cases, 
wliich  occurred  in  boys  aged  4  and  9  years  respectively.  In  all,  166  cases 
of  gangrene  occurring  in  infectious  diseases  were  collected,  and  of  these 
typhus  (42).  typhoid  (40),  and  influenza  (19)  furnish  the  largest  number. 
Five  followed  measles,  1  diphtheria,  and  1  varicella. 

Post-operative  scarlatina  is  met  with  occasionally.  Sir  James  Paget 
believes  the  patients  were  infected  before  the  operation.  Hoffa''  says  that 
these  should  be  termed  post-operative  scarlatinoid  erythemas.  A  case  of 
this  kind  was  seen  by  me  during  the  winter  of  1902. 


'  Article  on  "Scarlet  Fever"  in  "Twentieth  Century  Practice  of  Medicine," 
1898,  vol.  xiv,  p.  80. 

■' Deut.  Archiv.  f.  klin.  Med.,  vol.  Ixx,  Xos.  5  and  6. 

■■' In  Von.  Volkmann's  Sammlung  Klin.  Vortrage,  No.  292;  Chirurgie,  No.  90, 
188G-1887,  p.  2679. 


662 


THK  INFECTIOUS  DISEASES. 


Fig.  207. — Post-operative  Scarlatinoid  Erythema.      (Original.) 

A  child,  7  years  old,  was  taken  to  the  Manliattan  Ear  and  Eye  Hospital  and 
operated  for  hypertrophied  tonsils,  by  Dr.  N.  F.  Chappcll.  The  case  was  given  the 
usual  aseptic  care.      Two  days  later  I  saw  the  bov  with  a  well-definetl  scarlatina 


i 


SCARLET    FEVER.  663 

covenng-  hi.s  whole  bodj'.  The  mother  assured,  me  that  the  boy  was  not  exposed 
to  any  infection,  excepting  while  waiting  in  the  dispensary  with  other  patients.  The 
otitis  media  and  necrotic  pseudo-membranes  on  the  tonsils,  also  desquamation,  cer- 
tainly completed  the  clinical  picture  and  strengthened  the  diagnosis. 

The  Diagnosis. — When .  fever  exists  accomjjanied  by  an  inflamed 
throat  and  an  eruption  over  the  body,  tlien  tlie  diagnosis  of  scarlet  fever 
can  be  made.  Later  on  we  have  desquamation.  The  most  charac- 
teristic early  symptoms  of  a  typical  scarlet  fever  are:  Intense  redness 
of  the  faucial  mucous  membrane,  sore  throat,  early  and  persistent 
vomiting,  fever,  thirst,  and  increased  pulse  rate.  The  tongue  is  very 
characteristic — strawberry  appearance.  (See  Plate  XVII.)  Sometimes 
an  attack  of  scarlatina  is  ushered  in  by  convulsions.  Older  children 
comj)lain  of  an  intense  headache.  There  is  marked  constitutional 
depression  and  aching  of  bones.  Von  Leube  maintains  that  vomiting 
occurs  more  often  as  an  initial  symptom  in  this  than  in  any  other 
disease,  excepting  pneumonia.  There  is  nothing  peculiarly  characteristic 
in  the  early  temperature  of  scarlet  fever.  It  remains  elevated  after  a 
sudden  rise,  and  subsides  gradually  by  lysis,  toward  the  end  of  tlie  first 
week. 

Drug  Eruptions. — Great  care  must  be  taken  to  learn  if  a  child  has 
received  belladonna,,  opium,  quinine,  or  antipyrin.  These  drugs  give  an 
eruption  similar  to  scarlet  fever.  We  should  always  learn  if  such  drugs 
have  l)eon  given  before  making  a  positive  diagnosis. 

Course. — Scarlet  fever  usually  runs  its  course  in  al)out  six  weeks  from 
the  beginning  of  illness.  The  disease  is  spread  by  the  walking  cases  who 
have  not  completely  desquamated.  It  is  also  spread  by  cases  in  the  early 
stages  of  the  disease.  Such  children  usually  complain  of  headache,  nausea, 
and  vomiting.  A  superficial  examination  or  a  careless  examination  of  these 
''spoiled  stomachs"  has  frequently  been  the  cause  of  the  spread  of  scarlet 
fever,  children  being  permitted  to  go  to  school.  In  the  pre-exanthematous 
type  the  diagnosis  is  difficult  unless  the  throat  is  carefully  inspected.  Xo 
eliild  should  be  permitted  to  attend  school  until  the  last  evidence  of  desqua- 
mation has  disappeared. 

Prognosis. — It  is  very  difficult  to  determine  the  outcome  of  a  case, 
especially  at  the  beginning  of  scarlet  fever.  A  mild  rash  may  have  serious 
complications  and  a  severe  rash  may  run  a  very  mild  course  without  com- 
plications. Individual  susceptibility  plays  an  important  part  in  forming 
an  opinion  as  to  the  outcome  of  any  case  of  scarlet  fever.  The  following 
symptoms  should  influence  an  unfavorable  prognosis:  continued  hyper- 
pyrexia; continued  vomiting;  delirium  or  other  cerebral  symptoms,  such 
as  convulsions  or  stupor;  an  irregular  anomalous  or  poorly  developed  rash, 
if  intense,  suggests  extreme  viriilence :  an  extremely  rapid  and  feeble  or 
irregular  pulse.    Great  stress  should  always  l)e  laid  on  the  condition  of  tlie 


(364  THE  INFECTIOUS  DISEASES. 

licavt.  Other  complications,  such  as  broncho-pneumonia,  or  diphtheria,  or 
kidney  disease,  shonhl  he  noted  as  very  serious  complications. 

Treatment.- — hohtiion  (tinl  ('((re:  The  first  thino-  to  do  in  a  case  oi' 
scarlet  lever  is  to  isolate  and  remove  all  healthy  children  and  adults.  Thu 
patient  should  be  given  in  charge  oi'  a  competent  nurse.  The  best  method 
of  isolation  is  to  have  one  or  two  rooms  on  tlie  top  Hoor,  with  a  southern 
exposure.  The  nurse  sliould  liave  a  c-a])  completely  covering  her  hair.  Her 
uniform  should  be  thoi'ouulily  boiled  after  using.  All  linen,  such  as  hand- 
kerchiefs, bed  linen,  etc.,  should  be  disinfected  by  soaking  in  1  to  2000 
bichloride  solution  before  being  washed.  I  liave  always  used  the  Japanese 
paper  handkerchiefs;  they  are  convenient  to  wipe  the  secretions  and  dis- 
charges from  nose  and  moutli,  and  can  be  burnt  when  soiled. 

A  sputum  cup  or  cuspidor,  containing  a  5-per-cent.  solution  of  car- 
bolic acid,  is  very  useful.  Tlie  urine  and  faeces  can  be  disinfected  by  adding 
either  a  saturated  solution  of  copperas  to  it  or  by  mixing  Javelle  water,  the 
ordinary  Labarraque's  solution  of  chlorinated  lime. 

The  physician  in  attendance  should  protect  his  clothes  by  wearing  a 
gown  which  he  removes  on  leaving  the  patient's  room.  He  should  walk  in 
tlie  open  air  at  least  an  hour  before  calling  elsewhere. 

Hygienic  Treatment. — The  temperature  of  the  room  should  be  from 
68°  to  73°  F.  Fresh  air  must  be  admitted;  hence  proper  ventilatici  is 
imperative.  In  winter  the  patient  should  be  well  protected  from  draughts. 
Sunshine  is  imperative,  although  the  eyes  should  be  shielded  from  direct 
sunlight.  A  tepid  sponge-bath  can  be  given  every  morning,  and  also  in  the 
evening,  especially  if  there  is  profuse  perspiration.  The  child's  linen  should 
be  changed  once  a  day.  When  the  eruption  causes  itching,  the  body  should 
be  rubbed  with  cold  cream,  carbolated  vaseline,  or  the  following  recipe  is 
very  useful : — 

IJ  Calamine    1  diachin 

Ung.   aq.   rosar 1  ounce 

M.  ft.  ungt. 

Sig. :      Apply  o^er  the  body  once  or  twice  a  day. 

Forchheimer  advises  the  addition  of  menthol,  1  per  cent.,  to  relievo 
itching.     This  can  be  added  to  the  above. 

General  Treatment. — Stimulate  the  Eniunctories:  The  l^owels  shoidd 
alwa3's  receive  attention,  whether  constipated  or  not ;  a  dose  of  calomel  or 
several  wineglassfuls  of  citrate  of  magnesia  or  villacabras,  in  wineglassful 
doses,  three  times  a  day.  will  be  found  very  serviceable. 

Lemon  juice  in  the  form  of  leniomule  is  very  serviceable  in  stimulating 
the  secretion  of  urine,  and  also  for  (pienching  thirst.  The  citric  acid  cer- 
tainly has  a  beneficial  effect  on  the  throat. 

I  have  always  seen  the  best  results  from  l-eeping  tlie  howeh  loose  and 


\ 


SCARLET    FEVER.  065 

the  l-idneys  active.    That  we  eliminate  toxic  products  in  this  manner  no  one 

can  deny,  and  we  certainly  can  do  no  harm  by  this  preliminary  treatment. 

Fever  can  also  be  reduced  by  the  use  of  the  following  mixture: — 

IJ  Tinct.    aconite    20  drops 

Spir.  mindereri 2  ounces 

Syr.  limonis   1  ounce 

M.  Sig.:  Teaspoonful  every  hour  until  sweating  is  produced,  for  a  child  5  to 
12  years  old.    Younger  children  one  half  the  dose. 

Weak  Pulse. — When  the  first  sound  of  the  heart  becomes  weak,  or  the 
two  sounds  lose  their  normal  tone,  stimulation  must  be  commenced.  The 
same  is  true  if  the  pulse  is  weak;  Vj^g  grain  of  strychnine  can  be  given 
every  three  hours,  or  oftener,  if  necessary.  It  must  be  borne  in  mind  that 
children  tolerate  strychnine  in  toxtemic  conditions  in  very  large  doses.  It 
is  a  good  plan  to  give  coffee  with  the  strychnine  or  to  coml)ine  it  Avitli  caf- 
feine or  musk.  Digitalis  is  indicated  if  the  pulse  is  weak  and  of  low  ten- 
sion. Champagne  or  whisky  is  tolerated  in  extremely  large  doses.  Henoch 
considers  camphor  one  of  the  best  stimulants  when  given  hypodermically 
every  two  or  three  hours : — 

IJ  Camphor    1  gram 

Ether    10  grams 

Sig.:      Use  hypodermically. 

Coma. — In  coma  the  subcutaneous  use  of  sodium-caffeine-benzoate 
stimulates  the  heart  and  arouses  the  child  from  stupor.  It  also  stimulates 
diuresis.  When  bloody  urine  exists  in  addition  to  gallic  acid,  suprarenal 
extract  or  its  alkaloid,  adrenaline,  can  be  used  in  very  small  doses. 

Digitalis  should  not  be  used  continuously,  as  it  irritates  the  stomach, 
and  in  its  stead  tincture  of  strophanthus  should  be  used. 

Spartein  sulphate,  ^/^  to  V,  grain,  injected  hypodermically,  with  dis- 
tilled water,  is  useful  in  cardiac  weakness.  When  meningeal  symptoms,  such 
as  delirium,  cannot  be  relieved  by  hot  baths,  and  bromides  internally;  then 
the  application  of  several  leeches  behind  the  ears,  over  the  mastoid,  will  be 
very  useful. 

Nephritis. — When  the  first  symptom  of  ne))hritis  appears  we  must  aid 
the  kidneys,  skin,  and  bowels  by  eliminative  treatment.  In  this  manner 
only  can  the  blood  pressure  be  reduced.  The  child  must  be  kept  in  bed, 
well  blanketed.  The  diet  should  consist  of  milk,  milk  and  seltzer,  milk  and 
cereals,  and  ])uttermilk.  If  the  stomach  is  irritable  then  the  milk  should 
be  peptonized.  When  extreme  repugnance  to  milk  exists,  then  chocolate 
may  be  sub<titut<'d  or  some  vanilla  flavor  added  to  the  milk.  For  thirst 
give  whey,  lemonade,  or  orangeade.  To  stimulate  diaphoresis,  hot  baths 
aided  by  hot  ])acks  will  be  serviceal)le.  The  temperature  of  the  l)ath  should 
be  100°  to  110°  F.  The  child  is  iminersed  from  five  to  ten  minutes.  The 
surface  of  the  body  must  Ije  continually  rubl)ed  during  the  bath.     The  pa- 


666 


THE   INFECTIULS  DISEASES. 


tient  when  taken  out  of  the  bath  is  phiced  between  hot  blankets  for  one 
hour,  so  as  to  aid  diaphoresis.  To  give  the  hot  pavh  the  child  should  be 
wrapped  in  a  blanket  wrung  out  of  hot  water,  temperature  100°  F.,  and 
then  covered  with  a  dry  blanket,  over  which  is  placed  a  rubl^er  cloth.  The 
blanket  can  also  be  covered  with  oil  silk. 

The  pulse  should  be  watched  during  the  bath,  and  the  child  should 

at  once  be  removed  if  signs  of 
weakness  appear. 

The  Hot-air  Bath.—V\-ACQ 
the  child  in  bed  and  cover 
with  two  blankets.  On  either 
side  place  hot-water  bottles 
or  hot  bags  of  sand  so  pro- 
tected that  the  child  cannot  be 
burned.  Over  these  place  a 
rublier  cloth  or  a  rain  coat. 
Over  the  rubber  place  another 
blanket.  Sweating  occurs  very 
easily  and  very  quickly  in  this 
manner.  In  an  emergency 
the  ordinary  flat-iron  can  be 
used  instead  of  the  hot-water 
bottles,  for  a  hot-air  bath. 

Pilocarpin  and  jaborandi 
are  such  cardiac  depressants 
that  they  are  merely  men- 
tioned to  be  condemned. 
Nitrogl3'cerine  is  very  valu- 
able. When  a  general  dropsy 
appears,  the  danger  of  effu- 
sion into  the  serous  cavities 
must  be  borne  in  mind.  When 
necessary  the  effusion  should 
be  relieved  by  aspiration.  The 
quantity  of  urine  passed  is  the  most  important  point  which  should  guide 
us  in  determining  the  result  of  the  treatment.  Tjiqiiids  should  l)e  given  to 
stimulate  diuresis.  The  microscopical  examination  of  the  urine  will  also 
show  improvement  as  it  progresses. 

If  the  quantity  of  urine  increases  and  the  percentage  of  albumin  de- 
creases, then  our  patient  is  improving.  The  disappearance  of  blood  cor- 
puscles and  casts  denotes  improvement.  One  of  the  best  drugs  to  aid 
diuresis  is  diuretine,  to  be  given  in  doses  of  3  grains  for  a  child  two  years 
old,  and  gradually  increased  until  5  grains  per  dose  is  administered.      This 


Fig.  208. — Coffe.v's  Glass  Apparatus  Devised 
for  Hypodermic  Saline  Injections.  The  tempera- 
ture of  solutions  can  be  seen  and  regulated  by  the 
thermometer.  A  second  thermometer  shows  the 
temperature  of  the  soluti<^n  as  it  enters  the  body. 
This  apparatus  can  also  be  used  for  colonic  flush- 
ings by  removing  the  needle  and  attaching  a  rec- 
tal tube. 


J 


SCARLET  FEVER.  667 

drug  should  be  given  at  least  three  times  a  day  to  stimulate  the  kidneys. 
Another  drug  highly  recommended  by  Prof.  Baginsky  is  theocine.  It  can 
be  given  in  the  same  dosage  as  diuretine  and  the  dose  repeated  several  times 
a  day.  This  drug  will  produce  a  copious  flow  of  urine,  and  can  be  recom- 
mended because  it  does  not  disturb  the  stomach.  Now  and  then  I  have 
noticed  that  marked  vomiting  followed  the  administration  of  almost  any 
drug  during  the  course  of  nephritis ;  hence  great  care  should  be  taken  not 
to  be  prejudiced  and  condemn  a  drug  during  the  course  of  nephritis  with 
toxic  or  uraemic  symptoms,  if  the  patient  vomits. 

Salt-free  Diet} — When  the  kidneys  are  affected,  their  activity  is 
diminished,  and  an  excess  of  salt  is  stored  in  the  tissues.  As  each  molecule 
of  salt  requires  a  certain  quantity  of  water  to  hold  it  in  solution,  such  water 
will  be  abstracted  from  the  tissues,  giving  rise  to  the  dropsical  condition.  By 
giving  a  diet,  which  is  free  from  salt,  we  can  decrease  the  edema. 

Restorative  treatment,  such  as  iron,  strychnine,  malt  extract,  and  cod- 
liver-oil  should  be  given  after  the  symptoms  of  nephritis  subside.  The 
child  should  be  kept  well  protected  for  at  least  two  months  after  the  first 
symptoms  appear. 

As  soon  as  the  temperature  falls  to  the  normal  point  we  can  give : — - 

I^     Mist,  ferri  et  ammoiiii  acetatis 1  fluid  ounce 

Glycerini    1  fluid  ounce 

Aquae    q.   s.   ad  4  fluid  ounces 

]\I.     Sig. :     A  teaspoonful  or  more  every  three  hours,  in  water. 

Or  Basham's  mixture  may  be  given : — 

I^     Tinct.  ferri  chlorid, 

Acid,  acetic  dil.,  of  eacli    1   fluid  drachm 

Liq.    amnionii   acetat    ....    6  fluid  drachms 

Aquic    q.   s.   ad  6  fluid  ounces 

M.     8ig. :     'J'ahlespocmful  three  times  daily  for  a  child  six  years  old. 

Endorardilis  or  Pericarditis. — The  heart  requires  careful  watching, 
especially  if  symptoms  of  rheumatism  appear.  Sudden  death  will  fre- 
quently occur  from  heart  failure. 

A  case  of  tliis  kind  was  seen  by  me  in  consultation  with  Dr.  S.  Straus,  of  Xew 
York  City,  in  wliicli  ;i  cliild  desquamating  with  scarlet  fever,  had  myo-  and  endocar- 
ditis. Tliere  was  a  general  anasarca.  Tlie  pulse  became  very  weak  during  the  hot-air 
bath.  The  child  died  suddenly.  It  is  very  apparent,  theiefore,  that  the  hot-air  bath 
is  not  without  its  dangers. 

Otilis.- — 'I'he  escape  of  pus  from  the  oxtorual  auditor}^  canal  is  by  no 


'L'Echo  Medical  du  Nord.  January  20.  1007.  p.  25.) 
=  Read  also  chapter  on  "Acute  Otitis  Media." 


668  THE  INFECTIOUS  DISEASES. 

ineaus  rare.  The  extension  of  a  streptococcus  inflammation  from  the 
pharynx  through  tlie  Eustachian  tubes  can  sometimes  be  aborted  by  local 
treatment.  Too  great  stress  cannot  be  laid  on  the  active  antiseptic  treat- 
ment of  the  nasopharynx  as  a  means  of  })ro})hyla.\is.  When  earache  occurs, 
no  matter  how  sligbt,  then  the  ears  shoukl  be  examined.  It  is  better  to  call 
an  aurist  to  make  sure  of  the  diagnosis  and  treatment,  rather  than  risk  the 
dangers  of  mastoid  inflammation,  witli  tbe  possible  extension  of  a  menin- 
gitis and  a  fatal  outcome.  Until  then,  local  treatment  such  as  the  appli- 
cation of  a  hot-water  bag  to  the  car,  or  cotton,  inserted  into  the  ear,  will 
afford  temporary  relief.  The  danger  of  using  cocaine  shoidd  not  be  for- 
gotten, although  it  is  a  valuable  remedy.  When  pus  is  evident,  as  shown 
by  the  bulging  of  the  membrane,  then  a  paracentesis  should  be  performed, 
and  the  cavity  irrigated  with  boric  acid  solution,  or  equal  parts  of  hydro- 
gen peroxide  and  sterile  water.  The  ear  should  not  be  packed  with  gauze, 
but  should  be  permitted  to  discharge  and  drain  freely.  Restorative  treat- 
ment, such  as  has  been  previously  mentioned  in  conjunction  with  nephritis 
in  this  chapter,  is  indicated. 

Diet. — Generally  speaking,  during  the  febrile  stage  and  until  the  end 
of  the  second  week,  an  exclusive  liquid  diet  of  milk  or  milk  and  barley 
water  should  be  given.  If  milk  is  not  well  digested  then  whey  should  be 
tried  (see  "Dietary").  Later,  beef  soup,  mutton  or  chicken  broth,  butter- 
milk, all  gruels,  fruits,  fruit  jellies,  toast,  weak  tea,  weak  coffee,  cocoa,  and 
chocolate.  For  thirst — Appollinaris,  Vichy,  and  lemonade.  The  tendency 
to  nephritis  seems  to  be  lessened  by  giving  our  patients  a  milk  diet,  hence 
this  fact  must  be  borne  in  mind.  Steak  juice  and  cgg^  albumin,  diluted 
with  water,  can  be  given  later  on. 

Serum  Treatment. — Antistreptococcus  serum  has  been  extensively  used. 
It  has  its  opponents  and  some  who  extol  its  virtues.  Baginsky^  reports  a 
series  of  48  cases  treated  M'ith  serum,  of  which  7  were  fatal,  a  mortality  of 
14.6  per  cent. 

A  clinical  study  of  the  value  of  antistreptococcus  serum  was  reported  by 
me-  in  a  paper  read  before  the  Section  on  IVdiatrics  of  the  New  York 
Academy  of  Medicine. 

Antistreptococcus  serum  (Aronson's"')  was  sent  to  me  in  the  winter 
of  1903-1903.  The  serum  proved  very  successful  in  a  series  of  eases  in  my 
private  practice.* 

Throuijh  the  courtesy  of  Professor  Escherich  I  saw  a  number  of  cases 


"Berlin  Klin.  Woch.,  189G,  No.  33,  p.  340. 

-See  "Value  of  Antistrejitocofciis  Serum,"  May  12,  LSOS.  Published  in 
Archives   of   Pediatrics    (Louis   Fischer). 

■'  1  am  indebted  to  Messrs.  Scheriuf^'  &  (ilatz  for  sondinfj  me  sufficient  serum 
for  clinical  trial. 

■'  See  my  article  in  the  New  York  Medical  Record,  March  7,  1903. 


SCARLET    FEVEH. 


669 


that  were  treated  by  Moser's  antistreptococciis  serum  at  the  Children's  Hos- 
pital in  Vienna  while  in  Europe  in  May,  1903. 

All  of  these  serum  cases  did  remarkably  well.  I  was  impressed  by  the 
excellent  results,  especially  by  the  distinct  fever  crisis,  after  the  necessary 
dose  of  serum  was  injected.  The  streptolytic  serum  made  by  Stearn  is  well 
worth  trying  in  severe  scarlet  fever. 

The  following  case 
occurred  in  my  private 
practice : — 

Hannah  S.,  8  years  old, 
was  first  seen  by  nie  Febru- 
ary    '20th,     in     consultation 
with  Dr.  L.  Kohn.     The  his- 
torj'  given  me  was  that  the 
child    had    been    sick    three 
days,  with  a  temperature  of 
104°  F.  the  day  previous  and 
104  Vs"  F.  to-day.    The  pulse 
was  weak  and  rapid.    Large 
necrotic  patches  covered  the 
entire       surface       of       the 
pharynx,  tonsils  and  uvula. 
There   was   a   marked   fietor 
of   the   breath.     A   very   in- 
tense   eruption    covered   the 
entire      body.        Diagnosis : 
X  carl  at  ill  a.      There    was    a 
loss  of  appetite  and  a  gen- 
eral apathetic  condition.    At 
the  time  of  the  injection  of 
the  serum,  the  following  con- 
dition was  noted:     Tempera- 
ture   104'/,°    F.,    pulse    138, 
respiration     20.       Owing    to 
the  severe  general  infection, 
I  decided  to  give  an  injection 
of   20    cubic    centimeters    of 
antistreptococcus  serum.    On 
February  2.3d,  I  saw  the  case 
a     second     time     with     Dr. 
Kohn   and   note<l   the   entire 
disappearance     of     the     ne- 
crotic patches  in  the  throat, 
was  already  apparent  on  the 


Fig.  200. — T<Mni)craturc  Thnrt  from  a  Case  of  Scar- 
let Fever  Treated  with  Antistreptococcus  Senmi. 
(Original.) 

The  attending  physician  told  me  that  this  condition 
third  day  after  the  serum  injection. 


The  specific  action  of  antitoxin  in  di])liil)(Tia  is  far  greater  compara- 
tively than  the  action  attained  from  the  use  of  this  antistreptococcus  serum. 
The  clinical  results  were  certainlv  striking. 


()70 


Till':   INFECTIOUS  DISEASES. 


The  Temperature. — The  effect  of  the  serum  on  the  temperature  shows 
that  it  did  inhibit  bacterial  products.  Within  twelve  to  twenty-four  hours 
after  the  serum  injection  I  have  seen  a  distinct  crisis  in  the  temperature. 
In  other  cases  the  temperature  was  gradually  reduced  by  lysis.     (Fig.  209.) 

Another  interesting  observation  in  most  cases  is  the  disappearance, 
almost  melting  away,  of  the  necrotic  membranes  after  the  fourth  day.  The 
glands  of  the  neck  were  swollen  and  subsided  with  the  disappearance  of  the 
throat  manifestations.    The  vital  i)oint  consisted  in  a  strengthening  diet  in 


Fig.  210. — I\Ietlio(l  of  Nas;(l  Syringing  ciiipluycd  in  tlio  Scarlet  Fever 
Ward  of  the  Riverside  Hospital.     (Original.) 

addition  to  strict  hygiene.  I  feel  warranted  in  advocating  the  use  of  this 
new  serum  in  t'he  treatment  of  scarlet  fever. 

Medicinal  Treatment. — The  Throat:  Wlien  children  are  old  enough 
to  use  a  gargle  they  should  be  given  a  mild  antiseptic  solution  such  as  table- 
salt  solution,  using  a  pinch  of  salt  to  a  wineglassful  of  lukewarm  water. 
Gargle  every  hour. 

A  spray  consisting  of  1  to  2000  bichloride  directed  against  the  pharynx 
and  tonsils  every  hour  is  useful.  If  spraying  is  difficult,,  then  swabbing  the 
throat  with  cotton  dipped  in  bichloride  is  equally  good.  High  temperature 
will  frequently  subside  if  the  nasopharynx  is  properly  irrigated. 

The  septic  accumulations  are  very  serious  and  cause  profound  toxsemia 
unless  cleansed  thoroughly. 


SCAllLET    FEVER.  671 

Warm  solutions  of  1  per  cent,  iclitliyol  repeated  ever}'  six  hours  are 
recommended  by  Seil^ert.  Local  applications  of  50  per  cent,  resorcin  solu- 
tion in  alcohol,  applied  on  cotton  several  timeg  a  day,  are  also  advised. 

Kasal  Douching. — My  jjreference  has  always  been  for  mild  saline 
douches.  Hold  the  child  firmly  and  cleanse  the  nares  with  a  nasal  tip 
attached  to  a  fovmtain  syringe,  at  a  height  of  no  more  than  two  feet.  Per- 
manganate of  potash,  several  crystals  to  a  pint  of  water,  is  very  good  when 
there  is  fcetor. 

Sulphurous  acid  has  been  strongly  advocated  by  some.  I  saw  some 
excellent  results  from  its  use  while  on  duty  at  the  hospital  during  the  sum- 
mer of  1902  in  necrotic  scarlatinal  angina. 

Suljjhurous  acid  has  Ijeen  used  l)y  me  and  certainly  can  be  recom- 
mended when  extensive  necrotic  patches  exist : — 

IJ  Acid  .sulphurous   (U.  S.  P.) 1  tlrachm 

Aquae    i 8  ounces 

M.      ^ig-'-      One  teaspoonful  every  two  or  three  hours. 

^Yhen  the  acid  used  is  of  full  strength,  allow  it  to  stand  a  few  minutes 
before  giving  it  to  the  patient,  so  as  to  permit  the  gas  to  escape;  otherwise 
it  will  be  too  irritant. 

If  it  is  refused  an  injection  can  be  made  with  a  small  glass  syringe, 
throwing  the  medication  as  far  back  as  possible. 

R  Natrium  .sozoiodol, 

Flor.  sulphur of  each    equal  parts 

M.     For  insutllation  into  the  nostril  three  or  four  times  a  day. 

This  seemed  to  exert  a  very  beneficial  effect  on  the  necrotic  tissue, 
causing  a  clearing  of  the  throat. 

If  the  treatment  causes  nausea  or  vomiting,  then  the  sozoiodol  natrium 
can  be  given  internally  in  tlie  following  manner: — 

I^  Natrium   sozoiodol    ".       2.0 

Aquae    100.0 

M.  D.      Sig. :      Teaspoonful  every  hour. 

Swollen  Lymph  Glands. — In  septic  scarlet  fever  with  necrotic  pseudo- 
membranes  in  the  throat,  the  adjacent  lymph  glands  will  be  swollen. 

At  times  there  is  an  extensive  ojdema  and  infiltration  extending  into 
the  glottis  which  can  result  in  asphyxia. 

Such  cases  will  be  benefited  by  the  use  of  thorough  inunctions  of 
Crede  ointment.^  It  must  be  distinctly  understood  that  no  result  will  be 
noted  unless  the  ointment  is  rubljcd  into  the  swollen  glands  at  the  angle 
of  the  jaw  for  at  least  fifteen  minutes.  This  can  he  repeated  several  times 
a  dav. 


■  Schering  &  Clatz,  agents,  New  York  City, 


072  THE  INFECTIOUS  DISEASES. 

I  also  have  used  iiniDctions  along  tlio  s2)ine  to  promote  absorption  over 
a  greater  area.     This  has  pro\eu  very  eHieaei<nis  in  many  cases. 

Forchlieimer  advocates  the  use  of  sterile  normal  salt  solution  subcu- 
taneoiislj.  This  is  done  to  stiuiuhite  diuresis  and  also  to  aid  in  the  elimi- 
nation of  toxins.  In  my  own  practice  1  have  found  nuirked  benelit  from 
irrigating  the  colon  with  a  rectal  tube  introduced  about  six  inches,  using 
screral  pints  of  nornial  salt  solution  at  a  tcinperaiure  of  110°  to  115°  F. 
This  is  a  very  rapid  and  convenient  method  in  an  emergency,  especially 
when  one  is  luuupered  bv  necessary  irrigators  and  needles,  as  we  requiic 
only  an  ordinary  fountain  syringe  and  the  rectal  catheter  connected  with  it. 

Immunity  from  Diphtheria. — An  injection  of  500  to  3000  antitoxin 
units  will  confer  immunity  from  diphtheria  in  a  case  of  scarlet  fever. 

Diphtheria. — If  diphtheria  complicates  scarlet  fever,  then  the  usual 
treatment  of  diphtheria  should  be  instituted  (see  chapter  on  "Diphtheria"). 

At  the  Riverside  Hospital  every  ca^e  of  scarlet  fever  is  injected  with 
500  to  1000  diphtheria  antitoxin  units  as  a  prophylactic  measure.  By  this 
means  Dr.  Eichardson  believes  that  M'e  have  reduced  the  complication  of 
diphtheria  in  about  50  to  75  per. cent,  of  all  cases. 

Fever. — The  use  of  tepid  water  as  an  antipyretic  measure  is  the 
safest  means  of  reducing  fever  without  depressing  the  heart.  Each 
fever  should  be  studied  by  noting  how  nmcli  depi'ession  is  caused  by 
it — how  the  child  stands  the  temperature.  Jf  the  child  appears  bright  and 
cheerful  and  there  is  little  constitutional  disturbance  from  high  fever,  then 
cool  sponging  or  tepid  packs  may  be  ample;  if,  however,  there  is  marked 
depression,  then  a  warm  bath  may  serve  our  purpose  much  better.  When  a 
bath  is  used,  tlie  child  should  be  immersed  in  a  tub  of  water  having  a  tem- 
perature of  90°  F.,  and  after  the  patient  is  immersed  add  cold  water  or  ice 
until  the  temperature  of  the  water  is  reduced  to  S0°  F.  In  all  a  bath  should 
last  about  three  minutes,  not  longer  than  live  minutes.  It  is  important  to 
watch  the  pulse  while  the  child  is  in  the  bath.  The  temperature  should  be 
taken  before  and  about  ten  ndnutes  after  the  bath  to  note  the  fever.  We 
can  then  see  what  effect  has  been  produced.  Such  baths  may  be  repeated 
in  three,  four,  or  six  hours,  depending  on  the  individual  requirements. 

An  ice-cap  may  be  placed  on  the  head  after  the  bath. 
The  treatment  of  fever  is  of  the  greatest  importance.  When  there 
is  stupor,  drowsiness,  and  delirium,  llie  tc])id  bath  will  bo  indicated. 
Cold  packs  and  cokl  sponging  are  also  \aluable.  Antipyrinc,  phenacetine, 
and  quinine  are  extol h'd  by  some  and  condemned  by  others.  When  used 
they  should  always  be  combined  with  musk  or  camphor,  or  given  with  coffee 
to  counteract  the  well-known  cardiac  depression  caused  by  the  antipyretics 
belonging  to  the  coal-tar  series. 

In  the  treatment  of  high  temperature  in  scarlatina  and  infectious  dis- 
eases, injections  of  sulpho-carbolate  of  soda,  10  grains  to  a  pint  of  cool 


SCARLET    FEVER.  673 

water  (temperature,  70°  F.),  is  one  of  the  best  means  of  reducing  fever. 
These  injections  should  be  repeated  every  three  or  four  hours. 

"High  post-eruptive  temperatures  are  often  and  have  been  repeatedly 
traceable  to  infelicities  of  ingestion  and  digestion,  and  are  more  effectively 
relieved  by  prompt  and  sufficient  enemas  than  by  any  other  treatment 
These  high  post-eruptive  temperatures  repeatedly  arising  in  the  same  in- 
dividual have  been  accompanied  synchronously  by  sensible  increase  of  sub- 
maxillary swelling  and  tenderness,  followed  by  the  quick  abatement  of  these 
lymphatic  swellings  along  with  the  reduction  of  temperature  from  cooling 
antiseptic  enemas." 


48 


CHAPTER    X. 

DUKE'S  DISEASE^— (FOURTH  DISEASE). 

This  is  a  feeblj''  contagious  disease  with  very  slight  subjective 
symptoms,  and  characterized  by  a  '"maculo-papular  rose-red  rash,  more 
pronounced  on  the  cheeks,  legs,  and  outer  surface  of  the  arms.  Tlic 
specific  agent  is  unknown.  The  disease  occurs  in  ('})ideniies,  and  often  fol- 
lows an  outbreak  of  meask's  or  rotliehi.  It  is  found  to  spread  througii 
families,  and  a  number  of  cases  have  been  observed  at  tlie  same  time  in 
schools  and  kindergartens.  It  is  undoubtedly  carried  by  contagion,  but 
it  is  not  so  contagious  as  the  other  exanthemata." 

Children  between  the  ages  of  4  and  12  are  mostly  affected,  although 
infants  and  adults  may  also  be  infected.  The  disease  is  seen  in  both  sexes 
find  occurs  mostly  in  spring  and  summer.  Tlie  period  of  incubation  is 
from  6  to  14  days. 

Symptoms. — "The  disease  may  be  ushered  in  by  a  slight  feeling  of 
malaise,  weakness,  and  sore  throat,  but  in  the  majority  of  cases  the  first 
symptom  noticed  is  the  -eruption.  This  is  the  most  important  and  often 
the  only  symptom.  It  appears  invariably  on  the  external  skin,  and  no 
constant  changes  on  the  mucous  membranes  have. been  observed.  A  diag- 
nostic feature  of  the  disease  is  the  character  of  the  rash  on  the  face,  whore 
it  first  makes  its  appearance.  The  cheeks  are  chiefly  affected,  and  present 
a  symmetrical  rose-red  efflorescence.  The  skin  is  hot  to  the  touch,  and  is 
swollen,  but  it  is  not  at  all  sensitive  and  does  not  itch.  The  color  disap- 
pears on  pressure,  but  quickly  reappears.  The  whole  app(^arance  is  sug- 
gestive of  erysipelas.  The  eruption  is  confluent  over  the  cheeks,  and  the 
edges  are  well  defined,  slightly  raised,  and  distinct  from  the  normal  skin, 
but  it  may  gradually  fade  on  to  normal  skin.  The  area  of  confluent  erup- 
tion is  rather  sharply  limited  in  front  by  the  nasolabial  folds,  and  above  by 
the  temples.  Laterally  it  extends  to  the  angles  of  the  jaws.  The  skin 
around  tlie  mouth  appears  pale  in  contrast  to  the  livid  hue  of  the  cheeks. 
Discrete  spots,  varying  in  size  from  a  ])ea  to  a  Jiazel-nut,  are  often  seen  on 
the  forehead  and  chin.  The  rash  fades  from  the  face  after  four  or  five  days. 
About  the  second  day  the  eruption  makes  its  appearance  on  the  body,  Avhere 
it  is  most  marked  on  the  outer  surface  of  the  arms  and  legs.  The  trunk 
is  involved  to  a  much  less  degree,  and  may  be  almost  free,  but  in  no  case 
is  the  rash  so  intense  as  on  the  face  and  extremities.  The  eruption  spreads 
toward  the  periphery,  and  the  hands  and  feet  are  the  last  portions  of  the 


^  I  am   indebted  to   Shaw's  article  published   in  the  American   Journal  of  tho 
Medical  Sciences,  Januaiy,  1905,  for  many  valuable  points  in  this  article. 

(674) 


J 


t)rKK"S  DISEASE.  675 

body  to  be  affected.  On  the  extremities  the  exantlieui  is  typical  and  char- 
acteristic. It  is  iiiorliilliform  in  appearance,  and  not  so  deeply  rose-red 
as  on  the  face.  The  contour  of  tiie  eruption  presents  frequently  almost 
^•eographical  outlines,  and  in  many  cases  the  appearance  is  suggestive  of 
lacework,  especially  as  it  begins  to  fade  at  the  end  of  the  disease.  On  the 
inner  or  flexor  surface  of  the  arms  the  eruption  is  not  nearly  so  intense. 
It  is  apt  to  become  confluent  around  the  outer  surface  of  the  elbow.  On 
the  legs  the  eruption  is  similar  to  that  on  the  arms,  and  it  is  always  espe- 
cially well  marked  on  the  buttocks.  The  trunk  remains  comparatively  free 
from  eruption,  although  a  number  of  discrete  spots,  sometimes  crescentic  in 
form,  can  be  seen  sparsely  scattered  over  the  chest  and  back.  The  rash  is 
more  macular  than  papular,  and  shows  only  a  slight  elevation,  except  on 
the  face,  where  it  is  always  raised.  An  evanescence  is  often  observed  which 
is  perhaps  peculiar  to  this  disease.  The  rash  will  apparently  disappear 
when  some  slight  irritation  of  the  skin,  such  as  friction,  exposure  to  cold, 
etc.,  will  bring  it  out  again  in  full  bloom.  The  eruption  is  not  followed  by 
desquamation.  It  lasts  from  six  to  ten  days,  and  does  not  leave  any  stains 
or  markings  such  as  are  sometimes  seen  after  measles.  Xo  haemorrhage 
results  on  pinching  the  skin  as  occurs  in  measles  and  scarlet  fever.  The 
lymphatic  glands  are  not  enlarged  as  a  result  or  accompaniment  of  this 
disease. 

"The  subjective  symptoms  are  conspicuous  by  their  absence.  The 
tongue  may  be  slightly  coated,  but  it  never  presents  the  strawberry  appear- 
ance and  desquamation  of  scarlet  fever.  The  conjunctivae  are  not  con- 
gested, and  there  is  no  coryza  or  cough.     The  urine  is  normal." 

The  prognosis  is  excellent  and  no  coinplicaticm  or  sequehe  have  l)een 
iiiiscrvcd. 

The   treatment   is   symptomatic    Ihi'oughout. 

JiihlifKjrniiliy. 
1.  Tschamer:      Jahrbuch  f.  Kimlcilicilkiiiule,  188(),  Bd.  xxix. 
K  2.  Gumplowicz:      Ibid.,  1891,  Bd.  xxxii. 

"  3.  Tobeitz:      Arcliiv.  f.  Kiiulcrkiiuikheitt'n,  1896,  Bd.  xxv. 

4.  Escherioh:      Transactions  of  tin'  Eleventh  International   ^[o<lioal  Congress., 
Moscow,  1890. 

5.  Sclnnidt:      Wiener  klinisciie  ^^'ot'hens(•ll^ift,  1890.  Xo.  47. 
fi.  Stncker:      Zeitseliiift.  f.  praetisehe  Aeizte,  1899. 

7.  Berl)cri(li :      Inaugnral  Dissertation,  Giessen,  1900. 

8.  Feilelienfeld:      Deutsche  nied.  Wochenschrift,  1902,  No.  .33. 

9.  Trii)ker:      Kalender  f.  Frauen  nnd  Kinderiirzte,  Kniznack.  1901. 

10.  I'laclite:       Berliner  klinische  Wochenschrift,   1904,  Xo.  9. 

11.  Ilciiiiann:      Jahrbuch  f.  Kinderlieilkunde.  February,  1900. 

12.  Escherich:      Ibid,  1904,  Xo.  22. 
U.  Dukes:      London  Lancet,  July  14,  1900. 
14.  Ker:      The  Practitioner,  February.  1902. 

ir>.  Fosi>isehill:      Wiener  klinisciie  Wochenschrift.  1904,  Nos.  7,  25. 
IG.  Shaw:      American  Journal  of  the  Medical  Sciences,  January,  1905. 


CHAPTEK  XI. 
VARICELLA  (CHICKEN-POX). 

Varicella  is  a  specific  infectious  disease  of  an  acute  character.  The 
eruption  consists  of  vesicles  which  appear  in  successive  crops.  The  attack 
lasts  in  all  from  four  to  fourteen  days.  After  one  attack  the  child  is  usually 
immune  during  the  rest  of  its  life. 

Etiology. — This  disease  is  seen  only  in  young  children;  the  older  the 
child  the  loss  liahle  it  is  to  have  chicken-pox.  Nurslings  are  frequently 
afflicted. 

Hutchinson  states  that  in  his  experience  adults  are  almost  absolutely 
immune  from  this  disease.  In  my  own  practice  the  majority  of  cases  seen 
l)y  me  have- been  in  children  between  the  second  and  tenth  years  of  age. 

Pathology. — The  pathological  lesions  are  confined  wholly  to  the  epi- 
dermis. '"The  vesicles  contain  granular  fibrin,  a  moderate  cellular  exudate, 
cellular  debris,  and  serum;  this  differs  markedly  from  the  exudate  in  variola, 
which  is  usually  very  rich  in  cells,  especially  plasma  cells.  The  pock  in 
varicella  is  shallow,  rarely  involving  the  papillae  of  the  cutis,  and  as  its  con- 
tents are  absorbed,  the  superficial  covering  is  cast  off  in  the  form  of  a 
brownish  scab,  sometimes  with  marked  pigmentation,  but  no  resulting  scar. 
The  occurrence  of  a  scar  following  the  varicella  lesion  is  occasionally  seen." 

Diagnosis. — The  distinguishing  features  of  varicella  are:  "(a)  Its 
mild  prodromal  symptoms,  which  may  be  wholly  absent,  (b)  The  appear- 
ance of  the  eruption  on  the  trunk,  where  it  is  usually  more  abundant  than 
on  the  face  and  hands,  (c)  The  multiform  character  of  the  eruption,  its 
superficial  position,  comparable  to  drops  of  water  sprinkled  over  the  skin, 
and  its  appearance  on  the  same  region  in  successive  crops,  (d)  Its  mild 
constitutional  symptoms  and  short  duration;  the  disease  usually  terminates 
within  from  five  to  fourteen  days,  (e)  Varicella  is  mildly  infectious  and 
always  gives  rise  to  a  like  disease." 

A  nursing  infant,  about  five  months  old,  refused  the  breast,  and  seemed  to 
show  a  general  malaise.  The  infant  had  previously  enjoyetl  good  health.  Tlie 
nursing  was  regularly  carried  out  and  the  bowels  were  nonnal.  The  temperature 
was  100°  F.  There  v^as  no  cough.  On  the  second  day  of  this  malaise  several 
vesicles  appeared  on  the  abdomen  and  back.  Later,  some  vesicles  appeared  on  the 
buttocks,  thighs,  and  in  the  roof  of  the  mouth.  There  was  no  constitutional  dis- 
turbance and  on  the  third  day  of  illness  the  infant  again  nursed  as  usual.  Several 
successive  crops  appeared,  and  each  eruption  remained  about  three  days.  Local  treat- 
ment consisted  in  dusting  the  parts  with  cornstarch.  Bathing  was  prohibited  and 
small  doses  of  calomel  were  given.     No  complications  followed. 

(676) 


VARICELLA. 


677 


Differential  Diagnosis. — This  disease  may  be  confoimded  with  variola, 
as  some  mild  cases  of  variola  resemble  chicken-pox.  "The  superficial  strata 
of  the  epidermis  are  principally  involved,  and  a  serous  exudate,  which  is 
frequently  the  first  symptom  of  the  disease,  occurs  at  this  point,  resulting 
in  a  transparent,  thin-walled  vesicle,  while  in  variola  the  shot-like,  deep- 
seated  induration  and  subsequent  vesicular  formation  are  sufficiently  dis- 
tinctive to  warrant  a  differential  diagnosis.  The  lesions  in  varicella,  as  a 
consequence,  are  easily  destroyed,  and  when  seen  present  a  transparent, 
beady  appearance,  some  of  which,  having  ruptured,  leave  excoriated  areas; 
whereas  in  variola  it  is  impossible  to  rupture  the  lesions  so  as  to  evacuate 
the  entire  contents  without  numerous  punctures  or  by  totally  destroying  the 
diseased  area." 


BMe 

1 

2 

3 

4 

5 

6 

7 

8 

9 

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99^^ 

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M 

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^^ 

Fig.  2n. — Temperature   Curve   in  Varicella.      (Original.) 

In  variohi  we  have  more  uniformity  of  development:  first  papules  fol- 
lowed by  pustules  and  ending  in  desiccation,  leaving  black  crusts.  In 
chicken-])ox  we  find  a  varying  of  lesions  at  the  same  time,  so  that  we  may 
have  macules,  vesicles,  and  pustules  at  one  and  the  same  time.  In  variola 
the  eruption  is  thickly  seen  on  the  face  and  hands,  the  exposed  portions  of 
the  body.  In  chicken-pox  the  eruption  is  seen  on  the  abdomen  and  back; 
the  parts  protected  by  clothing  are  usually  first  covered.  When  called  to 
doubtful   cases  the  following  points  are  worth  noting: — 

V nihil icatiou  is  seen  in  suia/ljio.r ;  it  is  ahsnil  in  chicken-pox.  "The 
length  of  time  since  vaccination,  niul  wlictber  or  not  the  patient  has  ever 
had  chicken-pox.  (Smallpox  is  extremely  seldom  encountered  within  three 
or  four  years  after  vaccination,  while  after  that  time  the  number  of  cases 
of  varioloid  or  abortive  smalljiox  steadily  increases.  Chicken-pox,  like 
smallpox,  occurs  but  once  in  the  same  individual.     Prodromal  symptoms 


678  THE  INFECTIOUS  DISEASES. 

are  always  present  for  several  days,  usually  three,  in  variola ;  absent  or  of 
a  few  hours'  duration  in  varicella. 

""The  temperature  often  renders  valuable  aid  in  differentiating  between 
the  two  diseases.  In  variola  it  rises  rapidly,  and  even  in  mild  or  abortive 
cases  usually  reaches  10;)°  to  104°  F..  when,  on  the  appearance  of  the  rash, 
a  crisis  takes  place  and  it  falls  to  the  normal  within  a  few  hours,  Avhere  it 
may  remain  throughout  the  remainder  of  the  disease.  Varicella,  on  the 
contrary,  is  seldom  ushered  in  witli  fever,  but  the  tem})erature  usually  I'ises 
one  or  more  degrees  as  the  eru])tion  develo])s.  When  the  case  is  seen  for 
the  first  time  after  the  erujjtion  has  appeared  and,  as  often  occurs,  no 
definite  history  can  be  obtained,  other  symptoms  must  be  relied  ujx)!!." 

Varicella  nuiy  also  resemble  impetigo.  Impetigo  is  first  seen  on  the 
face,  especially  about  the  mouth  and  nose.  It  is  also  seen  on  the  hands. 
In  studying  the  regional  appearance  of  the  eruption  one  can  readily  see 
the  transmission  and  inoculation  from  face  to  hands  and  vice  versa.  This 
condition  is  never  met  with  in  chicken-pox.  Impetigo  may  last  weeks  and 
months.  Chicken-pox  rarely  exists  more  than  two  weeks.  Impetigo  is 
contagious  and  not  infectious.  Chicken-pox  has  been  successfully  inocu- 
lated. 

Prognosis. — The  prognosis  is  invariably  good.  I  have  never  heard  of 
a  fatal  case  of  chicken-pox.  Complications  should,  however,  be  guarded 
against  and  not  invited  by  carelessness. 

Treatment. — A  child  suffering  with  chicken-])ox  should  be  put  to  bed 
and  strictly  isolated.  Healthy  children  should  not  come  in  contact  with  a 
case  of  chicken-pox  for  at  least  two  weeks. 

The  diet  should  be  liquid,  and  feeding  should  be  given  at  regular 
intervals.  The  bowels  should  be  loose,  and  if  necessary  stimulated  by  the 
aid  of  a  laxative. 

For  the  eruption  flannels  and  woolens  should  be  avoided,  and  a  cool, 
loosely  fitting  linen  or  muslin  shirt  or  gown  should  be  worn.  It  is  safe  to 
prohibit  the  daily  bath  until  the  eruption  has  disappeared.  I  prefer  to 
dust  the  skin  with  some  l)land  dusting  powder  such  as  talcum,  corn  starch, 
or  rice  powder  several  times  a  day.  Iron  and  tonics  may  be  given  later  if 
required.  Locally,  a  paste  made  l)y  mixing  bicarbonate  of  soda  with  cold 
water  and  a})plied  to  the  chicken-pox  is  cooling. 

Baby  B.,  five  months,  old,  was  atteiuloci  by  ine  in  January,  1905.  Tbe  infant 
Jiad  a  severe  fonn  of  varicella  with  gastric  disturbances,  such  as  vomiting  and 
diarrhoea.  On  the  sixth  day  after  the  appearance  of  the  chicken-pox  the  infant 
scratched  its  arm.  On  the  folloM'ing  day  there  was  a  temperature  of  102°  and  a 
diffuse  swelling  surrounded  the  upper  arm.  There  was  marked  tenderness  and  pain 
on  the  slightest  motion.     The  swelling  increased.     The  arm  became  reddened  and  a 


VARICELLA. 


679 


diffuse  erysipelas  was  diagnosed.     The  temperature  increased  to  105  Vio°.      The  case 
was  then  seen  by  Dr.  A.  Jacobi  in  consultation. 

Treatment. — Local   treatment   consisting  of   evaporating  cooling  lotions;    lead 
and   opium  wash   and   bichloride   were   used   without  any   marked   benefit.      Crede 


1 

DATES  OF  OBSERVATIONS                              | 

(Ta 

r/- 

iO 

H 

/z 

f3 

f^ 

/4" 

i6 

Cent. 

Fahr. 

AMiPM 

am:pm 

am:pm 

AMiPM 

am:pm 

AMiPM 

am:pm 

41' ~ 

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-m'i 

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-  0 

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pi 

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•99'' 

1 

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i'^i — 

v 

y 

yy 

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-96°- 

B 

Fig.  21-^. — Erysipelas  Following  Varicella.  Locally,  pure  alcohol, 
in  which  ^/.^„,„  bichloride  mercury  was  dissolved,  was  applied  on  the  ery- 
sii)elatous  surface  continually.     Case  recovered.      (Original.) 


ointment  was  rubbed  into  the  axillary  glands  several  times  a  day.  An  injection  of 
II)  cubic  centimeters  of  antistreptococcus  serum  (Aronson)  seemed  to  have  very 
good  effect.  The  cooling  lotions  were  continued,  but  within  twenty-four  hours  after 
the  serum  injection  the  temperature  came  down  by  lysis  and  after  four  days  the 
temperature  was  nomial.      The  case  recovered. 


CHAPTER  XII. 


VARIOLA  (SMALLPOX). 


This  acute  infectious  and  contagious  disease  is  frequeutly  seen  in  un- 
vaccinated  children.  It  is  rarely  met  with  in  children  that  have  been  prop- 
erly vaccinated.  I  have  seen  smallpox  in  ver\  young  infants  and  children 
that  ivere  wwaccinated  during  my  service  at  the  Riverside  Hospital  in  the 
summer  of  1902. 


Fig.   21o. — Fatal  Smallpox  in  an    Unvacfinated  Four-weeks-old   Infant. 
Seventh  day  of  eruption.      (Kindness  of  Dr.  J.  F.  Schamberg. ) 

Etiology. — The  etiological  factor,  most  likely  a  specific  micro-organ- 
ism, has  not  yet  been  found. 

Among  unvaccinated  children  between  1  and  10  years  of  age,  some 
authors  state  that  58  per  cent.  die.  During  the  Sheffield  epidemic,  of 
2892   unvaccinated   children   under   10  years   of   age  living  in   infected 


Table  No.  91. — Showing/  Number  of  Cases,  and  Percentage  of  Mortality  {Allbuit'is  System) 


(680) 


Unvaccinated. 

Vaccinated. 

Cases. 

1131 
952 

607 

Deaths. 

Mortality 
Per  cent. 

Cases. 

385 
1468 
3080 

Deaths. 

Mortality 
Per  cent. 

Under  5  years  . 
5  to  9  years  .     . 
10  to  14  years  . 

647 

385 
155 

57.2 
40.4 
25.5 

30 
59 
90 

7.8 
4.0 
2.9 

Totals     .    .    .    . 

2690 

1187 

41.3 

4933 

179 

4.9 

VAEIOLA. 


681 


houses,  7.8  per  cent,  were  attacked.  During  the  Warrington  epidemic  54.5 
per  cent,  of  unvaccinated  children  under  10  years  of  age  were  attacked. 

It  is  a  curious  fact  that  the  resistance  of  children  is  less  than  that  of 
adults.  Nursing  infants  frequently  have  mouth,  nose,  and  throat  com- 
plications, which  seriously  interfere  with  their  feeding,  causing  death. 

There  are  three  tj^pes  of  variola : — 

Table  No.  92. 


Discrete 

1.  Natural  -{  Conflueut 

I 

[  Semi-conflueut 

f  l^urpiiric 

2.  Hsemorrliagic  ]  Hseniorrliagic 
Exudative 


Discrete  wheu  the  eruption  is  scattered. 


i  Confluent   when   the   eruption   is   thick    and 
\  flows  together. 

f  Senii-conflnent  when  the  eruption  is  discrete 
\         in  some  parts  and  confluent  in  others. 


3.   Motlifled. 


Anomalous 
Corymbose 


Corymbose  when   the   eruption  forms  groups 
or  clusters  on  various  i  arts  of  the  body. 


The  mode  of  infection  is  most  prol^ably  a  micro-organism  which  exists 
either  in  the  vesicles,  pustules,  or  crusts.  It  may  be  carried  in  the  air  so 
that  infection  may  take  place  at  souie  distance  from  the  body.  Some  au- 
thors believe  that  the  blood  of  smallpox  patients  contains  the  poison.  Small- 
pox can  be  transmitted  directly  from  person  to  person.  It  can  also  be  trans- 
mitted from  bedding  or  clothing  worn  l)y  an  infected  person.  Entering  a 
room  during  the  pustular  and  desquamative  stages  is  suflfieient  to  comnm- 
•licate  the  disease. 

Symptoms. — In  young  children  the  disease  is  usually  ushered  in  with 
convulsions.  The  pulse-rate  ranges  between  130  and  .KiO.  The  respira- 
t'on  is  labored  and  increased  in  frequency. 

Curschmann  believes  that  these  symptoms  are  due  to  an  irritation  of 
the  respiratory  centers. 

The  temperature  rises  rapidly  and  continuously  without  the  morning 
roiiiission.  Beginning  with  102°  or  103°  F.  on  the  first  day  of  illness,  tlie 
temperature  soon  reaches  105°  F.  (40.5°  V.)  until  the  eruption  a])])ears. 

With  the  first  appearance  of  the  eruption,  the  temperature  frequently 
drops  to  normal.  This  symptom  of  fever  occurs  in  no  other  exanthematous 
eruption. 

The  Eruption. — "Keddish  specks  or  dots  developed  into  papules  re- 
sembling flea-bites  appear  about  the  second  day.     After  the  papules  have 


682 


THE  INFECTIOUS  DISEASES. 


attained  the  size  of  a  small  pea  their  summits  gradually  assume  a  trans- 
lucent glazed  appearance  which  indicates  the  formation  of  a  vesicle.  As 
this  enlarges  a  central  depression  or  umbilication  takes  place  which  is 
looked  upon  as  characteristic  of  the  smallpox  lesion.  If  punctured  a  small 
amount  of  mucilaginous  serum  exudes.  The  eruption  is  not  confined  to 
the  skin,  but  is  met  with  in  the  mucous  membrane  on  the  mouth,  throat, 
and  nose. 


Date 

2 

3 

4 

5 

6 

7 

81 

9 

10 

IT 

12 

1 

105' 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

ME 

:me 

[ 

A 

f 

J 

' 

103° 
102° 

lor 

100" 
99° 
98° 

t 

) 

/ 

V 

'w 

\ 

V 

'\ 

\ 

\ 

V\ 

1 

I 

A 

V 

n 

— 

- 

A 

A 

-\ 

S 

J 

^ 

"^ 

— 

' 

■ 

^ 

^ 

L- 

^ 

^^ 

^ 

_ 

^ 

^ 

^ 

i^ 

Fig.  214  —Temperature  Curve  in  Variola.      (Original.) 


Stage  of  Suppuration.— On  the  sixth  day  of  the  eruption  there  is  a 
decided  yellowish  tint,  due  to  the  presence  of  pus  cells  or  polymorphonuclear 
leucocytes  resembling  cream.  The  face  usually  presents  an  erysipelatous 
redness. 

Stage  of  Decline.— About  the  twelfth  day  of  the  eruption  there  is  a 
spontaneous  rupture  of  the  pustules.  After  the  contents  are  thus  evacu- 
ated, or  by  absorption,  we  see  evidences  of  desiccation.  The  pustular  con- 
tents dry  up  and  the  pustule  dies,  leaving  a  blackish  crust.  These  blackish 
or  brownish  crusts  apjicar  first  where  the  eruption  took  place.  We  there- 
fore first  note  this  condition  on  the  arms,  palms,  and  soles.  The  crusts 
separate  from  the  body  between  the  sixteenth  and  twenty-first  days. 

Desquamation  of  a  furfuraceons  character  takes  place,  lasting  from 


VARIOLA. 


683 


one  to  two  weeks.  After  this  condition  has  disappeared  the  patient  may 
be  regarded  as  cured. 

Differential  Diagnosis.  —  Corlett  describes  the  great  resemblance  of 
smallpox  to  typhoid  fever  in  its  early  stages,  in  a  case  seen  by  him.  A 
strong  Widal  reaction  was  found,  besides  a  bronchitis. 

Measles  frequently  resembles  smallpox.  Catarrhal  symptoms  always 
present  in  measles  are  absent  in  smallpox.      The  lesions  in  measles  are 


Fig.  215.— Smallpox  in  a  Child  that  was  Vaccinated  During  the 
Incubation  Period.  Vaccination  performed  five  days  before  the  appearance 
of  the  variolous  eruption.  Little  or  no  modification.  (Kindness  of  Dr. 
J.  F.  Schamberg.) 

Hat,  soft,  and  velvety  to  tlie  touch.  The  papules  of  smallpox  are  small 
and  feel  like  shot  imbedded  in  the  skin. 

Scarlet  fever  sometimes  resembles  variola  of  a  mild  form.  The 
preiuonitory  sym))touis  of  variola  are  very  severe,  and  last  two  or  three 
days,  whereas  those  of  scarlet  fever  are  mild,  last  a  few  hours,  and  not  in- 
frequently are  entirely  overlooked.  The  rash  in  scarlet  fever  appears  on 
tbe  upper  part  of  tlie  body,  chest,  cheeks,  and  neck.  In  variola  a  scar- 
latinal forui  of  crupticm  is  seen  on  the  lower  part  of  the  abdotnen  and  on 
the  inner  surface  of  the  thighs.  It  is  bright  and  fiery  red  m  scarlet  fever 
and  dull  red  in  variola.  The  conspicuous  pa])iilae  or  strawberry  tongue  is 
l)resent  in  scarlet  fever  and  al)seiit  in  small])Ox. 

Inipetifjo  is  frequently  mistaken  for  small |)0X.  Corlett  describes  the 
presence  of  supposed  impetigo  in  Ohio  in  1898  which  gave  rise  later  on 


684 


THE  INFECTIOUS  DISEASES. 


I 


Fig.    210. — Mild    Discrete    Smallpox    in    an    Unvaceinated    Girl.     Note 
absence    of   lesions    upon    the    trunk.  (Kindness    of   Dr.    J.    F.    Scham- 

berg.) 


VARIOLA.  685 

to  an  epidemic  oi  smallpox.  Thus  it  is  apparent  that  there  is  a  great 
resemblance  between  impetigo  and  smallpox,  and  vice  versa. 

Chicken-pox  is  frequently  mistaken  for  smallpox.  I  have  already  out- 
lined the  differential  points  in  describing  chicken-pox  (see  chapter  on 
"Varicella"). 

Syphilis  may  sometimes  be  mistaken  for  variola.  A  study  of  the 
temperature  and  pulse  and  careful  observation  for  several  days  will 
usually  clear  up  the  diagnosis.  In  variola  the  eruption  assumes  a  pus- 
tular character  on  the  palms  and  soles. 

The  Prognosis  and  Course  are  always  bad  in  unvaccinated  children,  es- 
pecially in  the  very  young.     In  the  vaccinated  the  prognosis  is  always  good. 

A  series  of  cases  was  seen  by  me,  during  the  summer  of  1902,  in  tbe 
smallpox  wards  of  the  Xorth  Brothers'  Island  Hospital.  Out  of  twelve 
children  seen  not  one  had  been  vaccinated.  One  child  was  infected  by 
its  mother. 

As  a  rule  the  course  extends  over  three  weeks,  rarely  lasting  four  weeks. 
Complications  of  the  nose,  mouth,  and  throat  of  a  catarrhal  nature  are 
occasionally  seen.  The  outcome  of  the  cases  seen  by  me  was  quite  good 
in  spite  of  the  severe  character  of  the  disease. 

Complications. — Swelling  of  the  mucous  membrane,  such  as  oedema  of 
the  glottis,  bronchitis,  and  broncho-pneumonia,  frequently  complicates 
variola.  The  eruption  plus  secretion,  when  present  in  the  throat,  are  the 
cause  of  great  irritation,  and  give  rise  to  a  hacking  cough.  Suffocatory 
symptoms  may  follow  oedema  of  the  glottis.  Otitis  of  a  purulent  nature 
is  frequently  seen.    It  is  usually  accompanied  by  severe  neuralgic  pains. 

Treatment. — The  best  sanitary  surroundings,  fresh  air,  and  the  short- 
est possible  isolation  are  advisable.  The  local  application  of  a  solution  of 
glycerine  and  carbolic  acid  will  tend  to  relieve  the  itching,  and  to  soften  the 
crusts. 

The  bowels  should  be  kept  thoroughly  cleansed,  and  the  patient  made 
comfortable  by  a  tepid  pack  if  the  temperature  is  high  or  if  delirium  is 
present.  An  ice-cap  and  cold  colon  flushing  will  render  tbe  patient  more 
comfortable.  If  cardiac  depression  exists,  stimulation  with  musk,  cam- 
])hor,  or  champagne  is  advisable.  Regarding  sanitary  measures  the  New 
York  Health  Department  requires  the  immediate  removal  of  a  case  of  this 
kind  to  the  smallpox  hospital.  The  disinfection  and  thorough  fumiga- 
tion of  everything  which  was  in  contact  with  the  case  must  be  remem- 
bered if  we  wish  to  prevent  the  spread  of  the  disease. 

Varioloid   (Modified  Smallpox). 

The  symptoms  are  milder,  the  papules  less  in  number,  and  the  gen- 
eral condition  shows  an  infection  of  a  lesser  type  than  we  see  in  variola. 


686  THE  INFECTIOUS  DISEASES. 

The  febrile  symptoms  may  be  the  same  as  we  see  in  true  smallpox.  The 
attack  is  sliorter.  The  severity  of  the  symptoms  depends  on  the  lengtii  of 
time  since  the  last  vaccination  took  place. 

Vaccination. 

Jenner  noticed  that  milkmaids  in  Gloucestershire,  England,  who 
were  inoculated  with  cow-pox,  became  immune  to  smallpox. 

In  1798  he  published  this  discovery  and  gave  the  world  the  benefit  of 
the  protective  value  of  vaccination  against  smallpox. 

Tlie  serum  taken  from  a  vesicle  of  a  calf  which  has  vaccinia  or  cow- 
pox  contains  protective  properties  when  transported  to  living  beings,  ^yhen 
a  child  is  inoculated  this  same  immunity  can  be  transferred.  All  infants 
over  six  months  of  age  should  be  vaccinated.  When  smallpox  exists  in  the 
locality,  then  infants  of  any  age  should  be  inoculated  to  avoid  infection. 
The  nursing  infant  is  not  exempt  from  smallpox,  as  I  have  seen  several 
cases,  in  very  young  infants,  in  the  wards  of  the  Riverside  Hospital. 
When  infants  are  robust  and  in  good  health  there  can  be  no  contraindica- 
tion to  their  being  vaccinated.  Kegarding  older  children  that  have  been 
vaccinated,  it  is  safe  to  revaccinate  once  every  five  years. 

Symptoms. — From  five  to  ten  days  after  inoculation  a  red  areola  is  seen 
around  the  wound.  Inflammatory  symptoms  are  marked.  The  neighbor- 
ing lymph  glands  are  swollen. 

Constitutional  symptoms  such  as  fever,  anorexia,  general  malaise,  and 
thirst  are  noted.  This  condition  lasts  usually  from  two  to  three  days, 
rarely  longer,  unless  some  complication  follows. 

The  complications  are  erysipelas  and  cellulitis.  Abscesses  are  usually 
the  result  of  carelessness  or  infection.  This  infection  usually  takes  ]jlace 
at  the  time  of  inoculation  or  may  result  from  dirt  or  scratching  with  dirty 
nails  or  other  filthy  habits.     (l?ead  article  on  "Varicella.'') 

Syphilis  and  tuberculosis  are  frequently  mentioned  as  accidental  in- 
fections, })ut  I  have  never  seen  or  heard  of  a  bona  fide  case  resulting  from 
vaccination. 

Varieties  of  Vaccine. —  {a)   Humanized;  {!>)  bovine. 

Humanized  vaccine  is  rarely  or  never  used.  By  using  human  virus 
the  chance  of  conveying  syphilis  or  other  disease  has  been  thought  possi- 
ble.    Therefore,  the  bovine  virus  has  been  given  preference. 

Where  to  Inoculate. — Usually  on  the  arm,  although  the  leg  is  some- 
times preferred  for  females. 

Arm. — The  upper  third  of  the  arm  is  the  part  usually  chosen. 

Leg. — When  preference  is  shown  for  vaccination  on  the  leg  in  female 
infants,  the  lower  anterior  outer  third  of  the  leg  should  be  chosen. 

Good  vaccine  virus  will  take  on  almost  any  part  of  the  body. 


VACCINATION. 


687 


Fig.  217  shows  a  cdse  of  vaccination  which  I  reported  in  Pediatrics.  The 
child  was  vaccinated  on  the  arm  and  after  scratching  the  same  she  carried  some 
of  tlve  Tirus  from  tlie  arm  to  tlie  cheek,  causing  a  successful  vaccination. 

Method  of  InucululiotL — The  parts  to  l)e  iiiot'iilated  slioiild  l)e  e-leaiKHl 
with  soa})  and  water;  also  the  operator's  hands.  After  thorough  drying 
of  the  parts  with  cotton,  a  sterile  needle  should  he  used  for  scarifica- 
tion. A  small  scjuare  should  he  scratched  crosswise,  Init  no  blood  should 
he  drawn. 


Fig.  217. — Accidental  Vaccination  on  the  Cheek.  Sliowing  .successful 
vesicles  and  pustules,  marked  inflammation  and  oedema  of  the  lower  eye- 
lid.     Permanent  scar.      (Original.) 


No  antiseptic  should  be  used  to  clean  the  part  to  be  vaccinated,  other- 
wise we  destroy  the  vaccine  virus. 

Glj/cerinized  Lymph. — When  using  capillary  tubes,  break  off  the  ends 
and  blow  the  virus  on  the  scarified  area.  See  that  it  is  well  rubbed  into 
the  scarified  area  and  allowed  to  dry.  When  dry  protect  the  part  with  a 
sliield  or  a  sterilized  gauze  dressing. 

Ivory  Poiriis. — When  using  ivory  points  the  point  is  dipped  into  sterile 
water  after  it  has  scarified  the  area  to  be  inoculated.  The  moistened  serum 
should  then  I)e  thoroughly  rubbed  in  and  allowed  to  dry.  The  parts  are 
then  to  be  protected  against  infection  as  already  described. 

Welch  and  Schamberg,  in  a  series  of  cases,^  call  particular  attention 
to  the  great  difference  in  the  death-rate  between  the  vaccinated  and  the 


'Therapeutic  Clazette,  June  15,  1J)02. 


G88  'J^'JiJ'^  JNFja:Tioi;s  diseases. 

unvaccinated  patients.  Those  who  were  vaccinated  in  infancy  and  showed 
good  scars  gave  the  remarkably  low  death-rate  of  2.61  per  cent,  as  against 
the  high  death-rate  of  28.17  per  cent,  in  the  unvaccinated.  There  is  no 
doubt  that  all  those  who  showed  either  good  or  fair  scars  were  successfully 
vaccinated  in  infancy.  If  we  consider  them  together,  therefore,  the 
death-rate  is  4.84  per  cent.  In  making  a  comparison  between  the  vacci- 
nated and  unvaccinated  cases,  it  is  scarcely  fair  to  include  as  vaccinated 
all  the  cases  showing  poor  scars,  as  very  many  of  them  doul)tless  were 
never  successfully  vaccinated. 

Patients  who  had  been  vaccinated  seven  days,  or  less  than  seven  days, 
before  the  appearance  of  the  eruption  of  smallpox,  gave  a  death-rate  of 
35.71  per  cent.,  wdiile  those  who  had  been  vaccinated  for  a  longer  period 
than  seven  days  before  the  outbreak  of  the  efflorescence,  gave  a  death- 
rate  of  only  14.28  per  cent. 

Vaccinia. 

This  acute  condition  is  characterized  by  an  eruption  following  the 
inoculation  of  lymph.  When  lymph  is  taken  from  a  seropurulent  eruption 
on  the  teat  or  udder  of  a  cow,  it  is  called  cow-pox.  Some  authors  believe 
that  vaccinia  is  a  modified  form  of  smallpox. 

Symptoms. — An  eruption  resemlding  measles  or  scarlet  fever  sometimes 
follows  vaccination.  It  usually  involves  the  arms,  neck,  and  chest;  in  rare 
cases  it  involves  the  whole  body.  It  most  commonly  occurs  between  the 
eighth  and  eleventh  days  after  vaccination.  The  temperature  is  rarely 
above  normal  and  there  is  no  constitutional  disturbance.  There  is  no  treat- 
ment excepting  cleanliness.    Internally,  a  mild  laxative  may  be  given. 


PLATE  XIX 


Vaccinia  Followinj^  Vaccination.  Note  a  roseola  extending  over  the  left 
arm  and  leg.  also  the  face  and  ahdomcn.  There  were  no  constitutional  dis- 
turbances. The  rash  appeared  hetwecm  the  seventh  and  eighth  days  after 
the  vaccination.     It  lasted  two  days.      (Original.) 


CHAPTER  XIII. 

TYPHOID  FEVER. 

Typhoid  fever  is  an  acute  infectious  disease  caused  by  the  invasion  of 
a  specific  micro-organism,  known  as  Eberth's  typhoid  bacillus. 

Etiology. — Typhoid  is  rarely  seen  in  infants.  It  is  most  frequently 
seen  in  children  over  5  years  of  age.  In  a  series  of  97  cases  described  by 
Henoch : — 

2  cases  occurred  during  the  1st  year 
21  cases  between  the  2d  and    5th  years 
59  cases  betAveen  the  5th  and  10th  years 

Yon  Steffens  in  a  series  of  148  cases  reports : — - 

2  cases  occurred  during  the  1st  year 
28  cases  between  the  3d  and    6th  years 
34  cases  between  the  Gth  and  9th    years 

I  have  seen  typhoid  fever  in  an  infant  1  year  oUl  which  was  infected 
by  its  mother. 

Baginsky  describes  an  epidemic  of  typhoid  seen  by  him  in  Germany, 
in  which  16  cases  were  under  10  years  of  age. 

Infected  water  and  infected  milk  appear  to  have  caused  this  disease 
more  than  any  other  factor.  Baginsky  mentions  flies  as  an  occasional 
source  of  infection. 

The  New  York  Health  Department,  in  a  circular  of  information  con- 
cerning the  urine  in  typhoid  fever,  directs  attention  to  the  fact  that  "the 
typhoid  bacilli  are  present  in  almost  incredible  numbers,  estimated  at  many 
millions  per  cubic  centimeter." 

These  germs  find  a  suitable  culture  medium  for  their  i)ropagation  in 
the  intestinal  tract.  They  are  very  easily  found  in  the  fa?ces  in  the  living 
state  during  the  height  of  the  disease. 

The  entrance  of  the  typhoid  bacillus  into  the  gastro-intestinal  tract, 
whether  it  is  in  food.  li([uid  or  solid,  is  responsible  for  the  disease.  It  is 
true  that  a  rece])tive  condition  may  exist.  A  child  having  had  a  series  of 
gastro-intestinal  attacks  is  more  liable  to  an  infection  than  one  whose  diges- 
tive tract  is  normal,  liickcts  and  a  general  (lel)ilitated  condition  certainly 
favor  the  development  of  typhoid. 

Typhoid  fever  occurs  most  frequently  in  the  fall  of  the  year.  I  have 
seen  more  cases  of  typhoid  in  children  during  S(>])t<Mnl)er  and  October  than 
during  the  rest  of  the  year.  During  the  fall  and  winter  of  TOO"?  and  1903 
some  of  the  worst  cases  of  typlioid  with  hjcmorrhages  occurred. 

"  (689) 


690 


THE  INFECTIOUS  DISEASES. 


Bacteriology. — The  typhoid  bacillus  resembles  the  bacillus  •  coli  com- 
munis, and  is  found  chiefly  in  the  lymphoid  tissue  of  the  small  intestines, 
especially  in  Peycr's  patches,  where  it  produces  a  specific  inflammation. 
The  bacillus  is  found  not  only  -within  the  intestines,  but  in  the  glands  as 
well.  Neuhaus  found  the  bacillus  by  puncturing  the  roseolar  eruption 
and  examining  the  blood  therein.      It  has  also  been  found  in  laryngeal 


Table  No.  93. — Deaths  from  Typhoid  Fever  in  Children  Under  15  Years  of  Age- 

Old  City  of  New  York. 


0 
Years. 

1 
Year. 

2 
Years. 

3 
Years. 

4 

Years. 

Under  5 
Years. 

5  to  10 
Years. 

10  to  15 

Years. 

1890 

Males 
Females 

27 
27 

1 

2 
2 

1 

4 
1 

3 

8 
6 

9 

8 

10 
13 

1891 

Males                34 
Females             42 

1 
1 

3 
2 

1 
5 

5 
2 

3 
1 

13 
11 

12 
14 

9 

17 

1892 

Males 
Females 

37 
25 

1 
2 

4 
2 

2 

4 
1 

1 

1 

12 
6 

10 
14 

15 
5 

1893 

Males 
Females 

24 
19 

1 

2 

2 

2 

2 
1 

3 

7 
6 

12 

7 

5 
6 

1894 

Males 
Females 

25 

24 

2 

1 

1 
1 

1 
2 

1 

1 

5 
5 

9 
6 

11 
13 

1895 

Males 
Females 

24 

18 

2 

3 
1 

3 

3 

8 
4 

6 
6 

10 

8 

1896 

Males 
Females 

29 

27 

2 
2 

1 
2 

3 

3 

1 

9 
5 

11 
13 

9 
9 

1897 

Males 
Females 

17 
28 

2 

2 

2 
1 

2 

4 

1 

5 
9 

-     7 
9 

5 

10 

1898 

Males 
Females 

32 

17 

1 
1 

1 

2 
2 

1 
1 

5 

4 

9 

7 

18 
6 

1899 

Males 
Females 

13 

18 

1 

1 

1 

1 
1 

2 

3 

8 

7 
8 

1900 

Males 
Females 

30 

19 

2 

2 

2 

2 

1 

1 
2 

2 

3 

9 

8 

11 
6 

10 
5 

1901 

Males 
Females 

25 

28 

1 

3 

1 

2 
1 

2 
2 

4 
4 

Jl 
9 

6 
4 

8 
15 

Tot  1 

509 

21 

33 

28 

45 

38 

70 

201 

232 

TYPHOID    FEVER. 


691 


ulcerations  during  typhoid.     The  bacillus  was  also  found  in  the  purulent 

meningitis  accompanying  typhoid,  so  that  we  can  be  reasonably  certain 

that  the  bacillus  abounds  in  almost  every  part  of  the  body.      The  action 

of  typhoid  bacillus  on  the  human  system  is 

toxic.     Brieger   isolated   a   poison   from  the 

typhoid  bacillus,  which  is  called  the  typho- 

toxin. 

Pathology. — The  pathological  findings 
consist  in  an  inflammatory  condition  of  the 
mesenteric  glands;  besides  these  the  solitary 
and  agminated  glands  of  the  ileum  and  colon 
not  only  show  evidences  of  swelling,  but 
when  the  disease  progresses  it  frequently  ter- 
minates in  ulceration  and  necrosis. 

Occasionally  the  glands  will  show  a 
softening  and  pus  will  develop.  The  spleen 
is  usually  very  large  and  soft,  and  quite  pal- 
pable. When  the  disease  lasts  several  weeks 
and  there  are  evidences  of  a  distinct  toxaemia, 
the  poison  will  cause  a  marked  degeneration 
of  the  kidneys  and  liver,  also  affecting  the 
heart  muscles,  which,  later,  will  be  found 
very  soft  and  flabby. 

Morse^  reports  several  cases  of  faial  and 
infantile  typhoid. 

Festal  and  InfantUe  Typhoid. — In  re- 
gard to  icetal  typhoid  he  says  that  the  ty- 
phoid bacillus  can  transverse  the  abnormal, 
and  possibly  the  normal  placenta  from 
mother  to  foetus.  Other  organisms  may  also 
pass  in  the  same  way. 

Infection  of  the  fcetus  results.  Because 
of  the  direct  entrance  of  the  bacilli  into  the 
circulation,  intrauterine  typhoid  is  from  the 
first  a  general  septicaemia.  For  this  reason, 
and  possibly  also  because  the  intestines  are 
not  functionating,  the  classical  lesions  of 
intrauterine  typhoid  are  wanting. 

The  foetus  usually  dies  in  utero  or  at  birth  as  the  re>ult  of  the  typhoid 
infection. 

It  may  be  born  alive  but  foe])le  and  suffering  from  the  infection.     If 
so,  death  occurs  in  a  few  days  without  definite  symptoms. 

'Archives  of  Pediatrics  for  December.  1900. 


Fig.  218. — Ty])!ioi(l  Infantum 
in  a  2-Year-Old  Boy.  (a)  Soli- 
tary follicle;  (h)  small  agmin- 
ated gland;  (c)  Peyer's  patch. 
General  medullary  infiltration, 
no  ulceration.  Natural  size. 
(Langerhans.) 


692  THE  INFECTIOIS  DISEASES. 

It  is  possible  that  the  fa>tus  may  pass  through  the  infection  in  utero 
and  be  born  alive  and  well.    There  is,  however,  no  proof  that  this  happens. 

Infection  does  not  always  occur.  The  pregnant  woman  does  not  neces- 
sarily transmit  the  disease  to  her  child. 

As  to  infantile  typhoid  Morse  concludes  that  except  for  the  lessened 
exposure  in  the  first  year  through  food  there  seems  no  obvious  reason  wdiy 
typhoid  should  be  less  frequent  in  infancy  than  in  later  life.  Nevertheless, 
judging  from  the  small  number  of  cases  reported,  it  is  less  frequent.  It  may 
really  be  less  frequent,  or  only  apparently  so  because  the  disease  is  not  recog- 
nized, being  mistaken  for  other  conditions.  Bacteriological  examinations  in 
large  series  of  autopsies  on  infants  and  the  use  of  the  Widal  serum  test  in 
large  numbers  of  sick  babies  seem  to  offer  the  best  means  for  determining 
both  the  frequency  and  the  character  of  the  disease  at  this  age. 

The  accuracy  of  the  diagnosis  in  many  of  the  earlier  reported  cases 
must  be  regarded  as  very  doubtful,  and  hence  no  satisfactory  conclusions 
can  be  drawn  from  them.  Analysis  of  the  more  recent  and  certain  cases 
seems  to  show  that  the  symptoms  of  infantile  typhoid  are  essentially  the 
same  as  in  adults,  but  that  the  course  is  shorter  and  the  mortality  greater. 
These  conclusions  may  be  inaccurate,  however,  as  it  is  possible  that  they 
are  based  on  the  severe  cases  alone,  the  milder  cases  having  escaped  notice. 
The  pathological  changes  in  the  intestines  are,  as  a  rule,  insignificant.  The 
contrast  between  them  and  the  severity  of  the  general  symptoms  is  striking. 
The  probable  explanation  is  that  in  the  infant  as  in  the  fa3tus,  but  to  a  less 
degree,  the  disease  is  a  general  rather  than  a  local  infection. 

The  serum  reaction  occurs  in  infantile  as  in  adult  typhoid.  There  are 
no  data  as  to  whether  or  not  it  occurs  in  foetal  typhoid. 

Immuniiy. — The  agglutinating  power  may  or  may  not  be  present  in 
the  blood  of  infants  born  of  a  woman  with  typhoid.  If  present,  it  is  trans- 
mitted from  the  mother  to  the  child  through  the  placenta.  It  is  possible, 
however,  that  it  may  be  formed  in  the  child  in  response  to  toxins  trans- 
mitted through  the  placenta.  The  agglutinating  principle  can  pass  through 
the  normal  placenta.  Part  of  it,  however,  is  arrested  in  the  passage. 
Whether  or  not  it  is  transmitted  seems  to  depend  on  the  strength  of  the 
agglutinating  power  in  the  maternal  blood  and  the  length  of  time  during 
which  the  placenta  is  exposed  to  it. 

It  may  be  transmitted  to  the  nursling  through  the  milk.  It  may  appear 
in  the  infant's  blood  in  less  than  twenty-four  hours.  It  lasts  but  a  few 
days  after  the  cessation  of  nursing.  It  is  always  weaker  in  the  milk  than 
in  the  maternal  blood  and  always  weaker  in  the  infant's  blood  than  in  the 
milk.  This  weaken'ng  of  the  agglutinating  power  is  duo  to  the  obstruction 
to  its  passage  in  the  mammary  gland  and  in  the  nursling's  digestive  tract. 
The  chief  factor  governing  transmission  is  the  intensity  of  the  power  in 
the  maternal  blood.     A  sul)ordiDatc  but  important  factor  is  some  unknown 


TYPHOID    FEVER.  693 

condition  in  the  digestive  tract.  If  tlie  power  in  the  maternal  blood  is 
weak  and  the  obstacles  great  it  may  not  be  transmitted. 

Symptoms. — The  symptoms  are  visually  very  obscure  in  children. 
Vomiting  and  sometimes  diarrhoea  are  the  earliest  symptoms.  In  other 
cases  constipation  may  be  an  early  sym2:)tom.  The  so-called  pea-soup  diar- 
rhoea seen  in  adults  and  older  children  is  rarely  met  with  in  young  infants. 
Convulsions  frequently  usher  in  an  attack  of  typhoid  fever. 

In  older  children,  those  able  to  complain  will  usually  give  subjective 
symptoms,  which  may  aid  materially  in  making  the  diagnosis.  A  constant 
headache,  for  example,  Avill  always  show  a  severe  form  of  infection,  and 
may  be  the  only  symptom  which  will  be  constant. 

The  period  of  incubation  varies  from  five  to  fourteen  days.  We  can 
safely  say  it  is  rare  for  the  period  of  incubation  to  extend  over  three  weeks. 

The  Teiaperaiure. — The  temperature  is  one  of  the  mam  indications 
of  typhoid.  It  rises  at  night  and  falls  in  the  morning,  the  morning  fall 
being  less  and  the  evening  rise  greater  for  the  first  week  (step-laddder  type) 
until  the  maximum  is  reached.  The  temperature  shows  fairly  regular  oscil- 
lations, morning  fall  and  evening  rise  for  about  a  week.  It  then  returns 
to  normal  at  the  end  of  the  third,  sometimes  at  the  end  of  the  fourth  or  fifth 
week.     The  temperature  drops  by  lysis,  never  by  crisis. 

Secondary  fever  is  rare  in  children.  It  is  not  unusual  to  find  a  mild 
form  of  typhoid  terminating  normally  at  the  end  of  two  weeks. 

During  the  second  week  of  the  disease  when  the  temperature  remains 
fairly  constant,  the  diagnosis  will  be  much  easier,  although  a  positive  diag- 
nosis from  the  temperature  alone  should  not  be  made.  The  temperature  in 
a  mild  form  of  typhoid  in  an  infant  varies  between  101°  and  103°  F.  during 
the  first  week,  or  even  the  second  week,  of  the  disease.  Severe  cases  may 
show  a  temperature  of  105°  F.,  or  even  higher,  during  the  first  week  of 
the  illness.  The  temperature  may  show  peculiar  variations.  We  may  have 
a  sudden  rise  extending  over  a  period  of  six  weeks  instead  of  three  weeks. 
This  prolonged  pyrexia  sometimes  denotes  complications.  If  the  tempera- 
ture has  ranged  between  103°,  104°,  or  105°  F.,  and  suddenly  drops  to 
normal  or  sul)nornial,  then  we  must  suspect  cither  an  internal  hgemorrhage 
or  look  for  a  perforation.  Sudden  variations  in  the  temperature,  as  a  very 
sudden  rise  or  fall,  must  always  be  looked  upon  with  suspicion.  There  is 
no  crisis  in  typhoid  as  there  is  in  pneumonia. 

The  Pulse. — The  pulse  is  usually  increased  in  frequency  and  ranges 
between  130  and  160  per  minute.  The  force  and  rhythm  are  good  unless 
some  complication  arises.  The  pulse  is  usually  small  and  compressible,  and 
there  is  very  low  tension  in  fatal  forms  of  tlie  disease. 

Tlie  Tongue. — The  tongue  is  coated  with  a  whitish,  more  rarely  a 
brownish,  fur.     This  coating  extends  down  the  center,  although  the  whole 


694 


THE  INFECTIOUS  DISEASES. 


tongue  may  be  covered.  The  mouth  appears  very  dry,  and  the  patient 
sometimes  complains  of  intense  thirst. 

The  abdomen  is  usually  distended  with  gas  and  there  is  marked  tym- 
panites on  percussion.  Gurgling  and  tenderness  on  palpation  in  the  ileo- 
caecal  region  is  not  to  be  looked  upon  as  an  important  symptom. 

The  Spleen. — The  spleen  cannot  be  relied  upon  as  a  diagnostic  aid  in 
children.  While  it  may  be  enlarged  in  some  instances,  we  frequently  find 
that  it  is  not  j^alpable  in  many  cases  of  severe  typhoid. 

Coughs  and  Bronchial  Catarrh. — One  of  the  earliest  symptoms  in  ty- 
phoid is  bronchitis.  In  the  beginning  when  we  have  but  cough  and  fever 
the  diagnosis  will  be  quite  difficult.     Typhoid  frequently  simulates  pneu- 

The  Nervous  System. — In  profound  tox- 
icity the  nervous  symptoms  present  will  be 
muttering,  delirium,  and  a  semi-comatose 
condition.  Not  infrequently  rigidity  of  the 
muscles  of  the  neck  is  present,  so  that  the 
differential  diagnosis  from  meningitis  will 
be  difficult.  Tlie  nervous  symptoms  fre- 
quently resemble  those  seen  in  tubercular 
meningitis.  Acute  tuberculosis  may  some- 
times resemble  typhoid. 

Extreme  Emaciation.  —  Children  fre- 
quently show  emaciation  during  typhoid  for 
the  following  reasons: — 

1.  The  constant  fever. 

2.  The  low  vitality  owing  to  mal- 
nutrition. 

3.  The  system  being   constantly   drained   when   diarrhoea   exists. 

Diagnosis. — In  every  case  of  fever  in  which  a  diagnosis  cannot  be  made, 
a  drop  of  blood  should  be  examined  for  the  presence  of  the  Widal  reaction. 
This  reaction  is  always  a  trustworthy  evidence  of  the  presence  of  typhoid, 
and  a  negative  reaction  later  than  the  tenth  day  is  strong  but  not  absolutely 
convincing  evidence  of  the  absence  of  typhoid.  The  test  is  of  greater 
value  in  the  case  of  an  infant  than  an  adult,  as  we  can  exclude  the  occurrence 
pf  a  previous  attack.  Some  writers  state  that  the  reaction  is  seen  earlier 
in  children  than  in  adults. 

It  should  not,  however,  be  the  only  means  of  making  a  diagnosis.  It 
is  well  known  that  this  reaction  will  occur  months  and  sometimes  years 
after  the  patient  has  recovered  from  typhoid,  hence  great  caution  should  be 
used  in  relying  on  this  diagnostic  measure  exclusively. 

Widal  Test  for  the  Diagnosis  of  Typhoid  Fever. '^ — The  investigations 


Fig.  219.— Stages  in  Widal 
Reaction.       (After  Kobin. ) 


^This  method  is  described  by  the  Xew  York  Health  Department. 


TYPHOID    FEVER.  695 

of  Griiber,  Widal,  and  others,  jniblished  in  1896,  showed  that  the  blood 
of  persons,  suffering  from  or  having  recently  had  typhoid  fever,  contains, 
as  a  rule,  after  the  fifth  day  of  the  disease,  substances  which,  when  added 
to  a  broth  culture  of  the  typhoid  bacilli,  arrest  the.  characteristic  move- 
ments of  these  organisms  and  cause  them  to  become  clumped  together  in 
masses. 

The  results  of  a  very  large  number  of  examinations  made  here  in  New 
York  and  elsewhere  show,  that  if  the  blood  contains  agglutinating  sul)- 
stances  in  sufficient  amount  to  cause  a  prompt  and  marked  reaction,  when 
one  part  of  serum  or  blood  solution  is  added  to  10  parts  of  a  broth  culture 
of  the  typhoid  bacillus,  the  presence  of  a  previous  or  existing  typhoid  in- 
fection may  be  considered  as  extremely  probable,  and  that  if  these  sub- 
stances are  present  in  such  an  amount  as  promptly  to  produce  the  reaction, 
when  1  part  of  scrum  or  dried  blood  solution  is  added  to  20  parts  of  the 
culture,  the  presence  of  a  previous  or  existing  typhoid  infection  may,  for 
diagnostic  purposes,  be  practically  considered  as  established. 

In  estimating  the  diagnostic  value  of  a  negative  result  from  this  test, 
we  must  remember  that  the  reaction  is  rarely,  if  ever,  present  until  at  least 
four  days  after  the  appearance  of  symptoms ;  that  it  is  occasionally  absent 
in  cases  of  typhoid  fever  until  the  third  or  fourth  week,  or  even  until  con- 
valescence is  established;  that  when  developed  it  may  disappear  after  a 
few  days,  and  that  no  definite  relation  between  the  severity  of  the  disease 
and  tlie  degree  and  time  of  development  of  the  substances  causing  the 
reaction  has  been  established.  For  these  reasons  a  single  negative  result 
in  any  suspected  case  only  renders  doubtful  the  existence  of  typhoid  fever. 
In  those  cases  in  which  the  reaction  is  absent  after  the  ninth  day,  it  may 
be  reasonably  assumed  that  the  large  majority  will  not  prove  to  be  typhoid 
fever,  and  the  absence  of  the  reaction  in  all  of  several  different  cases  of  a 
suspected  group,  or  after  repeated  examinations  in  any  single  case,  affords 
evidence  of  very  decided  value  in  excluding  the  diagnosis  of  typhoid  fever. 

Directions  for  Preparing  Specimens  of  Blood. — The  skin  covering  the 
tip  of  the  finger  is  thoroughly  cleansed  and  then  pricked  with  a  clean 
needle  deeply  enough  to  cause  several  drops  of  blood  to  exude.  Two  large 
drops  are  then  placed  on  tlie  glass  slide,  one  near  either  end,  and  allowed 
to  dry  without  ])eing  spread  out  on  the  surface  of  the  slide.  After  they 
have  dried,  the  slide  is  placed  in  the  holder  and  returned  in  the  addressed 
envelope  to  a  culture  station,  or  mailed  to  tlie  laboratory. 

The  diazo  reaction  should  be  looked  upon  as  a  valuable  aid  in  making 
the  diagnosis.  It  is  described  in  detail  in  the  chapter  on  "TTrine,"page  023. 

The  Eruption. — The  eruption  consists  of  lenticular-shaped,  rose-col- 
ored spots.  They  are  small  and  slightly  elevated.  These  rose-colored  spots 
appear  at  the  beginning  of  the  second  week.  The  eruption  la.sts  about  ten 
days,  although  the  spots  last  from  two  to  three  days  and  are  succeeded  by 


696 


THE  INFECTTOrS  DISKASES. 


a  new  crop.     They  are  seen  on  the  thorax  and  aljdomen,  altliougli  at  times 
over  the  whole  hody. 

Lciicoixrnia  if  present  strongly  supports  the  diagnosis  of  typhoid.     In 
the  International  C'litiies  1909,  I  report  a  series  of  cases  in  which  the  white 
blood  cells  ranged  between  4000-GOOO  at  the  beginning  of  tlie  disease. 
■   Differential  Diagnosis. — Malaria  frequently  resembles  typhoid.     A  dif- 


Fig.  220.— Typhoid  Fever.— Severe  haemorrhages.     Fatal  result.      (Original  ) 


ferential  diagnosis  can  easily  be  iiuide  by  an  examination  of  a  drop  of  blood 
for  tlie  presence  of  plasmodia. 

The  administraticm  of  quinine  is  a  diagnostic  tost  of  practical  im- 
portance. An  irregular  or  irdertniilent  fever  which  yielch  promptly  to 
fiuinine  is  certainly  not  typhoid.  Tn  malaria,  the  temperature  will  be  found 
to  touch  normal  at  some  time  in  the  twenty-four  hours. 

Cholera  Infantum. — Many  eases  of  supposed  cholera  infantum  fre- 
quently prove  to  be  typhoid  fever.     I  have  seen  many  cases  in  midsummer 


TYPHOID    FEVER.  g97 

with  a  temperature  of  103°  F.,  having  roseola,  with  vomiting  and  diar- 
riicea.  In  such  cases  the  diagnosis  depends  on  the  presence  of  the  Widal 
reaction. 

\A'hen  diarrhoeal  sj'mptoms  and  fever  are  jsresent  in  the  early  stages 
of  typhoid  fever  it  is  extremely  difficult  to  make  a  diagnosis.  This  applies 
especially  to  the  first  week  of  the  disease  before  a  Widal  reaction  can  be 
made.  I  have  invariably  examined  the  urine  for  the  presence  of  indican 
(see  page  925).  When  the  symptoms  are  due  to  intestinal  autointoxication 
or  fermentative  conditions  in  the  intestine,  then  a  positive  indican  reaction 
is  present.  If  the  diazo-reaction  is  absent  and  indican  present,  we  can 
exclude  typhoid  fever. 

Internal  Hcetnorrltages. — Holt  reports  a  series  of  946  collected  cases 
in  which  hsemorrhage  occurred  in  30  cases,  about  3  per  cent.  The  ma- 
jority of  these  cases  were  over  10  years  of  age.  I  have  frequently  seen 
haemorrhages  in  children  between  5  and  10  years ;  never  under  5  years. 

Case  I. — A  case  of  typhoid  in  a  boy  16  years  old,  seen  in  consultation  with  Dr. 
Rayewsky,  had  a  series  of  haemorrhages  which  ended  fatally.  The  origin  of  this  ease 
was  supposed  to  be  an  infection  from  eating  raw  oysters.  The  boy  was  a  telegi'aph 
messenger  and  ate  some  oj'sters  in  the  street,  after  which  he  showed  signs  of  fever, 
and  intestinal  symptoms.  No  other  etiological  factor  was  ascertained.  The  boy 
was  in  good  health  and  suddenly  became  ill  after  eating  this  meal  of  oysters.  Symp- 
toms of  gastric  fever,  with  diarrhaui;  temperature  of  101°  to  103°  F.  gradually 
appeared.  The  symptoms  increased  from  day  to  day  until  delirium  and  general  coma 
were  present.  The  fever  was  difficult  to  control  in  spite  of  cold  tub  bathing.  The 
boy  weakened  from  constant  pyrexia — appeared  to  convalesce — when  a  severe  haemor- 
rhage occurred.  An  ice-bag  was  laid  over  the  abdomen,  and  opium  given  internally. 
The  colon  was  flushed  with  alum  and  water.     Nothing  seemed  to  control  the  bleeding. 

Case  II. — A  girl,  10  years  old,  was  seen  in  consultation  Avith  Dr.  H.  Wein- 
stein.  She  had  been  sick  about  three  weeks  when  seen  by  me.  She  was  apparently 
convalescing  when  she  had  a  haemorrhage  of  a  Aery  alarming  nature.  The  doctor 
told  me  the  child  lost  more  than  one  pint  of  blood.  The  pulse  was  about  130  and 
very  feeble  in  character.  The  child  was  deathly  pale  and  seemed  to  be  in  collapse. 
Whisky  and  strychnine  were  ordered  as  restoratives.  The  child  complained  of  cliills 
and  was  thoroughly  wrapped  in  warm  blankets  and  hot-water  bottles  Avere  applied 
to  her  feet.  A  teaspoonful  of  poAvered  alum  added  to  a  pint  of  cold  Avater  Avas  in- 
jected into  the  rectum  and  colon.  Paregoric  in  15  drop  doses  Avas  ordered  cA'ery  hour. 
The  nurse  AA'as  in.structed  to  Avatch  the  pupils  and  the  pulse  and  to  discontinue  the 
drug  as  soon  as  the  systemic  effect  of  the  paregoric  Avas  manifested.  Ice-cream  was 
ordered  internally  and  small  pellets  of  cracked  ice.  The  child  recovered  after 
careful  dietetic  and  restorative  treatment. 

InicsUnal  Perforation. — Intestinal  perforation  is  very  rare.  It  is  met 
with  in  about  1  per  cent,  of  all  cases.  A  sudden  fall  in  the  temperature 
with  collapse,  rarely  vomiting,  followed  by  tympanites,  are  symptoms  indi- 
cating perforation. 

Laparotomy  When  Perforation  Occurs. — The  skill  of  the  surgeon  will 
frequently  save  life  when  haemorrhages  occur.     In  a  case  of  typhoid  which 


698  THE  INFECTIOUS  DISEASES. 

progresses  favorably  during  the  third  and  fourth  week,  a  sudden  collapso 
should  be  an  indication  for  an  immediate  operation.  1  have  seen  death 
follow  a  case  of  this  kind.  These  cases  are  usually  hopeless  and  our  only 
chance  consists  in  resorting  to  an  immediate  operation. 

Complications. — Aphasia  is  occasionally  met  with.  Morse  reported  21 
cases.  Insanity  is  rarely  met  with  as  a  sequel  to  typhoid.  Chorea  is  fre- 
quently seen.  I  have  met  with  a  case  having  a  severe  form  of  choreiform 
movements  which  lasted  more  than  a  year,  following  the  attack  of  typhoid. 

Otitis  media  is  frequently  met  with  in  children.  It  is  very  important 
to  watch  the  ears  during  an  attack  of  typhoid. 

Less  frequent  complications  are  gangrenous  inflammation  of  the  mouth 
or  genitals,  pericarditis,  endocarditis,  peritonitis,  pyaemia,  abscesses,  and 
furuncles.  Abscess  of  the  liver  has  been  reported  by  Bokai.  Pulmonary 
tuberculosis  has  been  known  to  follow  typhoid. 

Prognosis  and  Course. — The  prognosis  is  more  favorable  in  children 
than  in  adults.  Tympanites,  if  accompanied  by  vomiting,  is  a  bad  sign. 
When  there  is  general  depression  and  nervous  symptoms  then  the  prog- 
nosis is  bad.  Singultus  is  usually  a  bad  sign.  Bleeding  should  always  be 
looked  upon,  especially  if  repeated,  as  a  bad  sign.  The  strength 
of  the  child,  its  assimilation  of  food,  and  the  condition  of  the  heart  should 
be  the  means  of  arriving  at  the  proper  prognosis.  Complications  should 
always  be  regarded  as  a  serious  matter.  The  prognosis  is  grave  if  the 
child  has  passed  through  a  typhoid  and  is  in  an  exhausted  condition,  and 
unable  to  cope  with  a  new  complication.  Baginsky  states  that  in  a  series 
of  68  cases  treated  by  him  in  the  hospital,  G  died,  a  mortality  of  8.8  per 
cent. 

In  children  typhoid  may  terminate  in  two  weeks.  It  may  extend 
over  three  weeks  or  even  four  weeks.  Mild  cases  of  typhoid  resem- 
ble an  attack  of  acute  gastric  fever.  Cases  are  occasionally  seen  in  which 
the  disease  terminates  abruptly  within  ten  days.  As  a  rule  older  children 
show  the  adult  type  of  fever  and  the  disease  runs  its  course  of  three,  four, 
or  six  weeks.  Infantile  typhoid  may  show  severe  gastric  symptoms,  such 
as  vomiting,  and  very  little  diarrhoea.  The  course,  therefore,  is  peculiar  to 
infants  and  entirely  different  from  that  seen  in  the  older  child. 

The  following  case  was  seen  by  me  some  time  ago.  A  woman,  35  years  of  age, 
was  taken  ill  with  typhoid  fever  of  a  veiy  severe  type.  She  nurseil  her  infant  during 
the  first  week  of  her  fever.  The  infant  was  then  1  year  old.  The  physician  ordered 
the  infant  weanetl.  About  one  week  later  the  infant  had  fever,  vomiting,  and  diar- 
rhoea. An  examination  of  the  blood  gave  a  positive  Widal  reaction.  The  infant 
recovered  in  about  fifteen  days.  The  mother  died  of  hemorrhages  during  the  third 
week  of  her  illness. 

Treatment. — The  specific  nature  of  the  disease  due  to  the  infection 
of  a  specific  germ,  has  caused  investigators  to  seek  a  typhoid  antitoxin.  As 
yet  no  definite  progress  has  been  made  in  this  direction,  although  inves- 


TYPHOID    FEVER.  699 

tigators  have  from  time  to  time  announced  the  discovery  of  a  healing  serum.^ 
In  the  ahsence  of  a  specific  serum  we  must  confine  ourselves  to  the  treat- 
ment of  indications.  In  the  beginning  a  good  dose  of  calomel,  ^/^  to  1 
grain,  repeated  several  times  a  day,  is  indicated. 

Fever  Treatment. — The  best  antipyretic  is  the  cold  bath  and  cold  pack. 
The  bath  must  be  properly  given  to  be  effective.  A  large  bath-tub  should 
be  procured,  large  enough  to  hold  the  child  at  full  length.  This  should 
be  half-filled  with  water  at  a  temperature  of  90°  F.  Cold  water  or,  in 
summer,  ice  shoidd  be  added  until  the  temperature  is  gradually  reduced 
to  70°  F.  This  is  an  agreeable  method,  as  we  avoid  the  sudden  shock  so 
dreaded  by  children  when  suddenly  immersed  in  cold  water.  The  dura- 
tion of  the  bath  should  be  from  three  to  five  minutes. 

The  temperature  of  the  child  should  be  taken  before  and  after  the 
l)ath.  The  child's  body  should  be  rubbed  continuously  while  in  the  bath 
><)  as  to  stimulate  the  circulation,  especially  so  when  the  water  is  cool.  If 
the  child's  pulse  is  feeble,  administer  a  stimulant  such  as  hot  coffee  or 
A\hisky  before  the  bath.  Watch  the  pulse  carefully,  and  if  the  slightest 
sign  of  weakness  is  noted,  remove  the  child  immediately  from  the  bath 
and  place  in  bed  with  hot-water  bottles  to  its  feet.  The  bath  should  be 
repeated  every  three  or  four  hours  or  oftener,  if  the  temperature  requires 
it.     If  the  temperature  is  not  modified  lower  the  temperature  of  the  bath. 

Antipyretic  drugs,  such  as  napthaline,  benzoate  of  soda,  quinine,  anti- 
pyrin,  antifebrin,  phenacetin,  and  lactophenin,  are  useless  in  combating 
fever  when  compared  to  cold  baths  and  cold  packs.  All  antipyretic  drugs 
of  the  coal-tar  series  are  such  cardiac  depressants  that  they  should  never 
be  prescribed  without  combining  them  with  camphor  or  musk.  Of  all  anti- 
pyretic drugs  I  prefer  phenacetin.  One  of  the  best  antipyretic  measures  is 
the  injection  of  several  pints  of  cold  saline  solution  through  a  catheter  into 
the  colon.  Too  much  hydrostatic  pressure  should  not  be  used.  The  irri- 
gator should  be  held  about  one  foot  over  the  child's  body ;  the  temperature 
'A'  the  water  should  be  between  60°  and  70°  F.  Flushing  the  colon  with 
cool  saline  solution  may  be  repeated  every  three  or  four  hours  if  a  good 
effect  is  apparent.  When  great  exhaustion  and  a  weak  pulse  exist,  then 
V,  teaspoonful  or  a  teaspoonful  of  alcohol  may  be  added  to  the  irrigation. 
The  main  point  to  remember  in  the  treatment  is  to  support  the  child  so 
that  the  strength  will  be  maintained  and  the  heart's  action  not  im- 
paired. With  this  object  in  view  nothing  is  better  than  restoring  vitality 
liy  the  aid  of  concentrated  food.  When  there  is  great  exhaustion  the  admin- 
i-( ration  of  a  normal  salt  solution  per  rectum,  or  its  use  by  hypodermoclysis,^ 
-liould  l)e  remembered.     One  or  two  pints  of  saline  solution  administered 


^  Einhorn,  of  New  York,  has  reported  beneficial   results  from  the  use  of  anti- 
typhoid serum. 

^  This  is  illustrated  in  detail  in  the  chapter  on  "Scarlet  Fever  Treatment." 


700  THE  INFECTIOUS  DISEASES. 

I^er  rectum,  with  the  hips  elevated,  is  frequently  tlie  means  of  stimulating 
diuresis,  thus  eliminating  the  poisons  of  the  toxins  through  the  kidneys. 
Great  care  is  required  in  giving  the  saline  in  the  form  of  hypodermoclysis. 
The  strictest  asepsis  should  be  maintained.  A  large  .aspirating  needle 
attached  to  a  fountain  syringe  (Fig.  208)  is  well  adapted  in  an  emergency. 
These  saline  injections  may  be  repeated  every  six  or  twelve  hours  if  required. 

Hygienic  Pleasures. — Owing  to  the  infectious  nature  of  the  discharges 
passing  from  a  typhoid  patient,  the  prime  requisite  is  the  thorough  disin- 
fection of  all  stools  and  urine.  If  there  is  cough  or  sputum,  the  same  must 
also  be  thoroughly  disinfected.  In  fact  all  discharges  should  be  received 
in  a  vessel  containing  a  strong  solution  of  javelle  water  (chlorinated  lime) 
or  a  5  per  cent,  carbolic  solution.  A  strong  solution  of  copperas  should  be 
thrown  into  the  toilet  from  time  to  time  while  a  typhoid  patient  is  in  the 
house.  All  bed  linen,  handkerchiefs,  and  dislies  coming  in  contact  with 
the  patient  should  be  soaked  in  a  bichloride  solution  for  at  least  one-half 
hour  before  being  washed.  Sunlight  is  of  the  greatest  importance  in  a 
room  having  a  typhoid  patient.  We  can  do  more  disinfection  with  sunlight 
and  fresh  air  than  we  can  with  medication. 

The  Food. — All  food  must  be  liquid;  no  solid  food  should  be  allowed. 
In  the  beginning  Avhey,  strained  soups,  and  broths  should  be  ordered ;  later 
strained  gruels,  cocoa,  acorn  cocoa,  and  chocolate  may  be  given  at  intervals 
of  two  or  three  hours.  In  some  cases  all)umin  water,  made  by  beating  the 
raw  whites  of  two  eggs  with  sugar  and  water,  is  useful.  I  frequently  give 
the  whites  of  six  eggs  per  day.  Milk,  buttermilk,  kumyss,  whey,  or 
junket  may  be  given,  alternating  with  soups  and  broths.  When  stimulation 
is  required  the  yolk  of  egg  can  be  combined  with  sherry  or  Tokay  wine. 
When  drugs  are  given  it  is  best  to  combine  them  with  soups  or  broths. 
When  severe  dyspeptic  symptoms  exist,  prcdigested  milk,  peptonized  with 
the  aid  of  pancreatin  and  soda,  must  not  be  forgotten.  When  milk  idio- 
syncrasies exist,  then  the  yolk  of  a  raw  egg  added  to  barley  water,  rice 
water,  or  almond  milk  (made  by  blanching  almonds  with  hot  water)  can  be 
substituted  for  milk.  When  thirst  exists,  unfermented  grape  juice  or 
water  acidulated  with  dilute  phosphoric  acid  or  dilute  hydrochloric  acid 
is  very  grateful.  Ten  drops  of  either  dilute  acid  can  be  added  to  a 
tumblerful  of  sweetened  water,  and  this  given  whenever  the  child  is 
thirsty.  These  acids  have  a  verv^  good  effect  on  febrile  affections,  and 
are  especially  indicated  when  diarrhoea  exists. 

Feeding  in  Convalescence. — The  great  danger  of  haemorrhage  should 
alwa3's  be  borne  in  mind ;  hence  it  is  advisable  to  abstain  from  giving  solid 
food  for  several  weeks  after  convalescence  is  thoroughly  established.  Soups 
thickened  with  sago,  farina  or  barley,  and  pea  and  lentil  soups  can  be  given. 
The  yolk  of  a  raw  egg  can  be  added  to  the  soup.  Milk  may  be  thickened 
with  zwieback.     The  main  diet  should  be  milk  and  cocoa  or  chocolate. 


TYPHOID    FEVER.  701 

Somatose  may  be  added  to  milk  or  soup.  Plasmon  is  also  beneficial. 
Bovinine,  liquid  peptonoids,  panopeptone,  eucasin,  or  tropon,  in  teaspoonful 
doses  added  to  milk,  are  very  valuable  during  the  convalescent  period. 
Valentine's  meat  Juice  given  in  milk  or  soup  is  nutritious,  or  Mosquera's 
liquid  beef  (made  by  Parke,  Davis  &  Co.)  can  be  added  to  each  soup  or 
milk-feeding. 

Drug  Treatment. — If  cerebral  symptoms  exist,  then  an  ice-bag  should 
be  applied  to  the  head.  When  there  is  severe  restlessness  and  insomnia, 
with  twitchings  of  the  muscles,  then  injections  of  3  to  5  grains  of  chloral 
hydrate  should  be  tried  per  rectum.  These  injections  are  best  given  in 
starch  water.  Five-grain  doses  of  sulphonal  or  trional,  repeated  in  two 
hours  if  necessary,  is  sometimes  very  effectual.  If  there  is  no  effect,  then 
Vi'4  grain  of  morphine  may  be  administered  hypodermically  for  a  child  2 
years  old. 

If  the  child  is  1  year  old,  then  V^g  grain  may  be  given,  and  repeated 
in  several  hours,  if  necessary.  The  greatest  care  must  be  maintained  if 
haemorrhage  exists. 

Bismuth  is  a  very  valuable  drug;  the  subnitrate  in  5  to  10-grain  doses, 
and  the  beta-naphthol,  in  5  to  10-grain  doses,  may  be  repeated  every  few 
hours  as  an  antifermentative. 

Tannaibin  or  tannigen,  in  doses  of  5  to  15  grains,  can  also  be  given 
every  two  hours.  If  the  hemorrhage  is  very  severe,  then  an  injection  con- 
taining 30  drops  of  Monsell's  solution  added  to  a  quart  of  cool  water,  or 
a  teaspoonful  of  alum,  may  be  added  to  a  pint  of  water.  These  injections 
can  be  repeated  every  three  or  four  hours  until  the  haemorrhage  ceases. 
Ice-bags  should  be  kept  continuously  on  the  abdomen  at  the  slightest  sign 
of  hemorrhage. 

Guaiacol  carbonate,  in  5  to  10-grain  doses,  repeated  every  three  or 
four  hours,  is  a  very  good  antipyretic.  Creosote  carbonate,  1  drop  for 
each  year;  for  a  child  1  year  old,  1  drop;  for  a  child  5  years  old,  5  drops, 
three  times  a  day,  is  one  of  the  best  Intestinal  antiseptics. 

"When  severe  tenesmus,  associated  with  flatulence  and  very  loose  stools, 
exists,  then  the  best  remedy  will  be  1  or  2-drop  doses  of  turpentine,  com- 
bined with  several  dro])S  of  paregoric.  The  oleoresin  of  turpentine  in  1 
or  2-grain  doses,  can  be  combined  with  V^o  grain  of  extract  of  opium  for 
a  child,  5  years  old,  in  the  form  of  a  suppository.  This  can  be  repeated 
several  times  a  day  if  the  symptoms  are  not  improving. 


CHAPTER  XIV. 

ERYSIPELAS. 

This  is  an  acute  infectious  and  contagious  disease.  It  is  characterized 
by  an  inflammatory  condition  of  the  skin,  the  subcutaneous  tissue,  the 
lymph  spaces,  and  the  lymph  vessels. 

Etiology  and  Bacteriology. — We  are  indebted  to  Fehleisen  for  a  study 
of  the  bacteriology  of  this  disease.  Fehleisen  found  the  streptococcus 
present,  so  that  it  is  positively  identified  as  the  cause  of  the  same.  The 
disease  may  also  originate  from  a  staphylococcus  aureus. 


5'. 


CL 


1^' 


Fig.  221. — Ectogenous  Streptococcus  Infection.  Eczema  and  erysipelas 
of  the  scalp  in  a  child  1  month  old.  (Bacteria  carmine  stain)  ;  (a)  cutis; 
(6)  subcutis  ;  (c)  lymph  vessels  filled  with  streptococci,  surrounded  by  an  inflam- 
matory area  ;  (d)  epithelial  covering;  (e, /)  elevated  horny  layer;  {g')  strep- 
tococci.    X  50.      (Ziegler. ) 

The  invasion  of  the  micro-organism  takes  place  through  an  abrasion 
of  the  skin  caused  by  scratching  with  a  dirty  finger-nail.     It  is  very  rarely 
epidemic,  but  can  spread  easily  from  patient  to  patient.     A  case  of  ery- 
sipelas is  a  source  of  great  danger  in  a  hospital  ward. 
(702) 


ERYSIPEIAS. 


703 


Pathology. — There  is  an  infiltration  of  the  tissues  and  they  are  usually 
swollen  from  an  accumulation  of  serum.  Under  the  microscope  we  can  find 
pus  cells  in  the  serum.  ^Yhen  this  condition  is  noted  abscesses  will  be 
found.  In  other  cases  gangrene  will  be  present.  There  is  nothing  char- 
acteristic found  in  the  lungs,  heart,  kidneys,  spleen,  or  liver  which  would 
be  distinctly  pathognomonic.  The  usual  conditions  found  in  sepsis  are  seen 
here. 

P  n  e  u  m  o  n  i  a  is 
sometimes  met  with  as 
a  complication. 

Symptoms.  —  The 
usual  type  of  erysipelas 
met  with  in  children 
is  known  as  erysipelas 
migrans.  This  is  known 
as  the  wandering  type 
because  it  spreads  rap- 
idly from  diseased  to 
healthy  parts.  The  tem- 
perature in  the  begin- 
ning varies  from  103° 
to  103°  ¥.,  and  may 
rise  to  10-1°  or  105°  F. 
Septic  cases  usuall}' 
show  a  much  lower  tem- 
perature. I  have  seen 
cases  of  a  decided  sep- 
tic nature  in  which  the 
temperature  was  99°  F. 
for  several  days.  The 
pulse-rate  varies  between  120  and  150.  The  flush  is  of  a  deep  red  color  and 
usually  very  shining.  The  following  case  seen  by  me  in  consultation  with 
Dr.  B.  Brodski  will  illustrate  severe  erysipelas: — 

Child  ^I.,  6  years  old,  sufTercd  with  severe  coryza  from  acute  rhinitis.  There 
was  an  artificial  eczema  due  to  excoriation  around  the  nose.  The  intense  itching 
caiised  the  child  to  scratch  the  parts  and  when  the  attending  physician  saw  this 
case  he  found  a  well-defined  erysipelas.  Local  remedies,  such  as  lead  and  opium 
wash,  and  warm  bichloride  were  used.  The  erysipelas  spread  over  the  face  and 
at  this  time  involved  the  eyelids  so  that  the  eyes  were  tightly  closed.  The  fore- 
head, nose,  and  cheeks  were  involved.     This  was  the  fifth  day  of  the  disease. 

Ten  cubic  centimeters  of  antistreptococcus  serum  were  injected.  The  tem- 
perature at  the  time  of  injection  was  10.3°  F. ;  the  following  day  the  skin  seemed 
to  desquamate  and  lose  its  fiery  red  appearance.  T  also  advised  thorough  inunctions 
of  unguentum  C'rede,  three  times  a  day.      With  the  aid  of  restoratives  and  good 


Ddte 

2 

3 

4 

5 

6 

7 

8 

9 

10 

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ME 

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103' 
102' 
101" 
100° 
99° 
98° 

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Fig.  222. — Fever  Curve  in  Facial  Erysipelas. 
(Original.) 


704 


THE  IXFECTIOUS  DISEASES. 


nutrition  tlic  case  recovered  in  about  six  days  after  the  above  treatment  whk  com- 
menced.    Xo  complication  ensued,  although  at  one  time  meningitis  was  suspected. 

Another  case  equally  instructive  was  seen  b}'  me  in  consultation  with  Dr. 
Henry  M.  Groehl : — 

Eaby  K.,  1  year,  was  seen  on  her  fifth  day  of  illness  by  Dr.  Groehl,  who  found 
a  well-marked  case  of  erysipelas  imolving  both  the  lower  extremities.  The  tempera- 
ture was  10475°  F.  The  child  was  very  restless.  The  flush  spread  to  the  back 
and  over  the  abdomen.  He  ordered  locally  lead  and  opium  wash  to  cool  the  surface, 
and  internally  he  gave  calomel  and  phenacetin  with  sparteine. 

On  the  sixth  di>x  the  child  was  much  improved.     Temperature  fell  to  99°   F 
pulse  was  good.     On  the  seventh  day  there  was  a  marked  change  for  the  worse.     Tlie 
temperature  still  remained  at  99°  F.,  the  pulse  was  rapid  and  feeble;  there  was  con- 


Fig.  223— Fever  Curve  in  Phlegmonous  Erysipelas.     (Original.) 


1 


tinuous  vomiting.  The  inflammation  suddenly  spread  from  the  abdomen  to  the 
chest,  almost  covering  the  child.  The  appearance  was  decidedly  septic.  The 
child  vomited  long  after  all  drinks  by  the  mouth  had  been  stopped.  In  fact, 
long  after  rectal  feeding  had  been  commenced  the  vomiting  persisted. 

On  the  eighth  day  of  the  illness  I  saw  the  case,  and  after  going  over  the  history 
and  treatment,  recommended  injections  of  10  cubic  centimeters  of  antistreptococcus 
serum.  This  was  injected  in  the  usual  aseptic  manner,  just  a.s  we  inject  antitoxin. 
On  the  evening  of  the  same  day  of  the  injection  there  was  no  reaction.  The  child 
continued  the  same. 

The  following  day,  about  three  hours  before  the  exitus  lethalis,  the  body  was 
covered  with  ecchymotic  spots.  The  various  parts  of  the  body  were  covered  with 
discolorations,  some  of  them  resembled  the  colors  of  the  rainbow. 

Complications. — The  cedenia  usually  seen  on  the  skin  is  a  very  fatal 
complication  in  erysipelas  affecting  the  air  passages.  In  such  cases  oedema 
of  the  glottis  Avill  result  fatally. 

Prognosis. — This  depends  upon  the  time  when  the  case  is  first  seen 


ERYSIPELAS.  705 

and  chiefly  upon  the  condition  of  the  child  at  the  time  of  the  infection. 
If  the  child  is  well  nourished  and  has  been  breast-fed,  the  prognosis  is  good. 

Treatment. — A  dose  of  rhubarb  and  soda  or  5  to  10  grains  of  phos- 
phate of  soda  should  be  given.  The  destructive  tendency  of  the  pathogenic 
bacteria  on  the  blood  should  be  remembered ;  hence  large  quantities  of  nor- 
mal saline  solution  should  be  given,  by  injection,  into  the  colon.  The 
strictest  hygienic  measures  must  be  used.  The  internal  administration  of 
active  diuretics,  such  as  spirits  nitr.  dulc,  are  indicated.  The  strength  of 
the  child  should  be  supported  with  proper  food,  so  that  it  can  throw  ofiE 
the  poison.  The  most  effectual  treatment  is  the  local  treatment,  especially 
if  fever  exists. 

Local  Treatment. — Pure  alcohol  in  which  bichloride  of  mercury  is 
dissolved,  should  be  applied  continuously  by  saturating  absorbent  cotton 
and  laying  the  same  over  the  erysipelatous  flush : — 

IJ  Alcohol    2000  parts 

Bichloride  of  mercury  1  part 

In  some  cases  lead  and  opium  wash  is  very  cooling  and  will  remove 
the  heat  from  the  affected  parts. 

Oil  silk  or  rubber  tissue  should  cover  the  wet  application  to  prevent 
evaporation.  The  inunction  of  a  10  per  cent,  ichthyol  ointment  has  been 
tried  by  me  with  some  success.  I  regard  the  use  of  Crede  ointment  as  a 
very  efficacious  remedy. 

CoUargolum  (Soluble  2IetalUc  Silver). — In  septic  scaiiet  fever  and 
in  severe  types  of  erysipelas  in  which  a  profound  toxaemia  exists,  rectal 
injections  of  collargolum  are  usefu4.  It  should  be  administered  in  the  fol- 
lowing manner: — 

ft  Collargolum 2'/*  to  4  7:  grains 

Aq.  dest 2  'A  ounces 

The  above  to  be  used  for  a  colon  injection  after  the  rectum  and  colon  have 
been  cleaned  of  faeces. 

Intravenous  injections  should  consist  of: — 

IJ  Sol.  collargolum 5  per  cent. 

Sig. :  Inject  10  to  30  minims,  with  a  hypodermic  syringe,  using  one  of  th^ 
veins  in  the  back  of  the  hand.  Study  its  effect  and  if  there  is  no  improvement  the 
same  may  be  repeated  two  or  three  times  a  day.  A  careless  injection  may  cause 
death — if  air  is  forced  into  a  vein. 

Serum  Treatment. — Since  the  streptococcus  has  been  found  to  l)e  the 
etiological  factor  in  erysipelas,  the  most  plausible  treatment  has  been  the 
anti-streptococcus  serum.  The  clinical  cases  described  in  this  chapter  show 
very  good  results  from  the  serum  treatment.  I  have  seen  specific  results 
after  using  10  to  20  cul)ic  centimeters  of  this  serum,  and  strongly  advise 
the  use  of  the  same  in  this  disease.^ 

*  Read  also  clinical  report  of  case  of  erysipelas  complicating  varicella  in  chapter 
on  Varicella,  page  (578. 


CHAPTEE  XV. 
MALARIAL   FEVER      (INTERMITTENT    FEVER— PALUDAL   FEVER— AGUE). 

This  is  a  specific  infectious  disease  due  to  the  invasion  of  a  distinct 
germ  belonging  to  the  class  of  protozoa.  It  is  known  as  the  plasmodium 
malaria?.  "The  disease  is  contracted  by  the  inoculation  of  the  human  sub- 
ject by  the  infected  mosquito.  The  plasmodium  malarise  passes  through 
one  cycle  of  its  development  in  the  body  of  a  variety  of  the  mosquito  known 
as  the  anopheles  cleviger." 

We  find  this  disease  in  Southern  Eussia  and  in  Italy;  in  our  own 
Southern  States  as  well.  In  the  Xorth  of  Europe  and  the  Xorth  of  Amer- 
ica it  is  rarely  found.  The  disease  is  usually  seen  in  swampy  regions  and 
where  bad  drainage  exists.  It  is  also  seen  in  the  tropics.  The  influence  of 
the  weather  is  interesting.  While  in  summer,  spring,  and  fall  cases  occur 
frequently,  in  extremely  cold  weather  they  are  very  rare. 

Bacteriology  and  Etiology. — Laveran,  in  1880,  discovered  the  specific 
germ  which  cavises  this  disease  in  the  blood  of  infected  individuals.  In 
America,  Councilman,  Abbott,  Osier,  and  many  others  have  confirmed 
Laveran's  observations.     There  are  several  types  of  fever. 

First. — The  middle  forms:  (a)  tertian,  double  tertian  (quotidian); 
(h)  quartan  fever  and  its  combinations. 

Second. — The  more  severe,  often  more  or  less  irregular  fevers  which 
occur  in  America  and  in  Italy,  most  commonly  at  the  end  of  the  summer 
and  fall,  called  the  a^stivo-autumnal  fever  of  the  Italians.  The  tropical  ma- 
laria of  the  Germans.  This  type  of  fever  includes  the  so-called  remittent 
malarial  fevers  as  well  as  most  of  the  cases  of  pernicious  malaria  and  other 
malarial  cachexia. 

Tertian  Fever. — Golgi's  description  and  differentiation  of  the  micro- 
organism of  the  tertian  and  quartan  t3'pe  of  malaria  have  remained  prac- 
tically unassailed.  "If  we  examine  the  blood  from  a  case  of  tertian  fever 
just  after  the  paroxysm,  we  find  in  certain  of  the  red  blood-corpuscles 
small,  round,  colorless  bodies  which  appear  to  have  a  slight  depression  in 
the  center,  and  when  stained  in  dry  specimens  show  a  paler  central  area 
with  a  darker  periphery.  These  bodies  examined  in  the  fresh  specimen 
show  active  amoeboid  movements.  A  few  hours  later  the  organism  will  be 
found  to  have  increased  somewhat  in  size,  and  to  contain  a  few,  fine, 
brownish  pigment  granules  which  dance  actively  under  the  eye,  the  motion 
probably  being  due  to  undulatory  movements  in  the  protoplasm.  On  the 
day  between  the  paroxysms  the  bodies  will  be  found  to  have  about  half- 
filled  the  red  corpuscles.  They  are  still  actively  amoeboid,  and  the  number 
o£  pigment  granules  has  considerably  increased.  The  rod  corpuscle  at  this 
stage  will  be  seen  to  be  a  trifle  larger  than  its  unaffected  neighbors,  and  to 
(706) 


MALARIAL    FEVER.  707 

be  considerably  decolorized.  On  the  day  of  the  paroxysm  the  organism  has 
entirely  filled  and  almost  destroyed  the  red  blood-corpuscle,  which  is  rep- 
resented only  by  a  faint  pale  rim  ahout  the  full-grown  parasite,  if,  indeed, 
it  has  not  entirely  disappeared.  The  pigment  granules  may  show  at  this 
stage  a  very  active  motion,  but  the  amoeboid  movements  of  the  organism 
as  a  whole  are  but  little  marked.  At  the  time  of  the  paroxysm  an  interest- 
ing change  takes  place;  the  pigment  gathers  together  in  a  more  or  less 
solid  clump,  usually  in  the  center  of  the  organism,  while  the  rest  of  the 
protoplasm  looks  somewhat  granular  and  shows  a  suggestion  of  lines  radiat- 
ing outward  from  the  center.  This  appearance  gradually  changes,  the  lines 
becoming  more  distinct,  until  finally  we  see  the  central  clump  of  pigment 
surrounded  by  from  fifteen  to  twenty  small  ovoid  or  round  glistening  seg- 
ments,  each  one  having   a   central   more   refractive   spot,   and   resembling 


Fig.  224. — Malaria   Plasmodia;    Ter-  Fig.  225. — Malaria  Plasmodia;  Trop- 

tian   Type.      Plehn-Chenzinsky's   Stain.  ieal   Form.     Romanowsky-Nocht  Stain. 

X  1000.  X  1000. 

strongly  the  hyaline  bodies  which  we  see  immediately  following  the  chill. 
This  segmentation  of  the  organism  is  always  coincident  with  the  paroxysm, 
and  the  presence  of  the  blood  of  a  segmenting  body  is  a  sure  indication 
that  the  paroxysm  is  present,  or  is  about  to  occur.  Immediately  following 
the  paroxysm  fresh  h^'aline  bodies  appear  in  the  red  corpuscles.  Though 
the  invasion  of  the  corpuscles  by  these  fresh  segments  has  never  been 
actually  observed,  the  evidence  that  this  occurs  is  so  strong  that  we  can 
-afely  accept  it  as  a  fact. '  Besides  these  forms  we  see  not  infrequently  small 
"v  large  extra  cellular  pigmented  bodies;  that  is,  organisms  resembling 
exactly  those  within  the  red  blood-corpuscles,  excepting  that  they  are  free 
in  the  blood  current. 

These  may  be  seen  at  times  to  break  up  into  several  smaller  bodies, 
while  at  other  times  they  may  show  a  long,  tail-like,  non-motile  process 


708 


THE  INFECTIOUS  DISEASES. 


containing  sometimes  a  few  pigment  granules.  They  are  probably  organ- 
isms which  have  escaped  from  the  red  corpuscles,  or  full-grown  bodies 
which  have  broken  up;  they  are  considered  to  be  degenerative  forms.  At 
times  also  we  find  the  so-called  flagellate  bodies.  Their  development  from 
the  ])igmented  organism  may  indeed  be  observed,  the  pigment  of  the  full- 
grown  body  becoming  very  actively  motile,  then  collecting  in  the  center 
of  the  organism,  while  several  long,  thread-like  flagella  burst  out  of  the 
bod}'  and  move  actively  about  among  the  surrounding  corpuscles.  Some- 
times we  may  see  one  of  these  flagella  which  has  Ijroken  away  from  the 
organism  and  is  moving  rapidly  through  the  field.  This  is  also  thought 
Ijy  the  Italians  to  be  a  degenerative  process.  The  characteristics  of  this  form 
of  organism,  which  is  observed  in  tertian  fever  alone,  are  so  marked  that 
with  a  little  study  of  the  parasite  one  can  make  a  definite  diagnosis  of  the 
type  of  fever  from  an  examination  of  the  blood  alone. 


Date 

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Fig.  226. — Tertian  Fever  (Intermittent  Fever).  Typical  malarial  tem- 
perature, usually  seen  in  the  spring  and  early  summer.  Onset  with  vomit- 
ing, diarrhoea  and  chills,  accompanied  by  a  well-marked  rigor,  and  coldness 
of  the  extremities.      (Original.) 


The,  Parasite  of  Quartan  Fever. — "Quartan  fever  is  not  at  all  common 
^n  this  country,  but  in  the  few  cases  which  the  writer  has  observed  the  or- 
ganisms differ  distinctly  from  the  tertian  parasite,  and  show  accurately  the 
characteristics  described  by  Golgi.  Here  the  first  stage  of  the  organism  is 
similar  to  that  observed  in  tertian  fever,  excepting  that  the  amoeboid  move- 
ments are  not  so  active.  As  the  body  develops,  the  rods  and  clumps  of  pig- 
ments are  larger  and  darker  than  those  in  tertian  fever,  while  the  amoeboid 
movements  of  the  organism  are  relatively  slight.  The  full-grown  forms  are 
materially  smaller  than  in  tertian  fever,  while  the  red  blood-corpuscles, 
instead  of  being  expanded  and  decolorized,  appear  at  times  shrunken  about 
the  body,  and  of  a  somewhat  deeper  old-brass  color   (messingfarbe).     In 


MALARIAL    FEVER. 


709 


segmentation  the  organism  divides  into  from  six  to  ten  different  parts  in- 
stead of  twenty  to  tliirty,  as  in  the  tertian  form. 

Tlie  Organisms  of  the  /Esiivo-autumnal  Fevers. — "The  organisms  asso- 
ciated with  the  a?stivo-autumnal  fevers  have  been  carefully  studied,  but 
much  remains  to  he  done,  particularly  in  this  country. 

"There  is  some  difference  of  opinion  as  to  whether  there  are  not  two 
types  of  organism  associated  with  these  fevers.  Some  Italian  observers 
divide  them  into  the  cpiotidian  and  the  malignant  tertian  organ  isms.  The 
differences  made  out  by  the  Italians  are,  however,  very  slight,  and  have  not 
been  observed  in  this  country.  In  the  first  place  we  see  Just  after  the 
paroxysm  small  hyaline  bodies  which  may  or  may  not  be  actively  amoeboid; 
these  can  sometimes  be  distinguished  in  that  they  are  generally  somewhat 
smaller  and  have  oftentimes  a  characteristic  ring-like  appearance.  In  the 
early  stages — during  the  first  week,  for  instance — of  an  attack  of  this  form, 


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Fig  227— Qtiartan  Fever  (Double  Tertian).  Onset  with  vomiting  and 
convulsions.  Convulsions  usually  accompany  each  paroxysm.  Restlessness 
associated  with  cyanosis  and  coldness  of  extremities.  These  cases  are  usually 
seen  in  the  late  autumn.     (Original.) 

we  nuiy  see  only  the  hyaline,  unpigmented  forms;  but  conmionly,  if  we 
observe  carefully,  we  may  see  some  time  after  the  exacerbation  of  tem- 
perature, shortly  before  tlie  l:)eginn;ng  of  another,  bodies  which  are  a  trifle 
larger  than  these  smallest  hyaline  forms  and  which  contain  one  or  two  very 
minute  pigment  granules  lying  near  the  periphery.  Just  before  or  during 
the  paroxysm  we  may  see  bodies  with  a  small  central  clump  of  motile  or 
non-motile  pigment  granules  lying  usually  in  cells  which  are  more  or  less 
shrunken  and  crumpled,  and  of  a  deeper  color  than  tlie  nornuil  corpuscles 
(messingfarbe).  These  bodies  are  generally  not  half  as  large  as  the  red 
corpuscles.  After  the  first  week  or  ten  days  of  the  disease,  or  after  treat- 
ment has  Ijeen  begun,  we  see,  however,  certain  very  characteristic  and  easily 
recognizable  forms  which  are  only  seen  with  this  type  of  fever.  These  are, 
first,  round  or  ovoid  bodies  about  the  size  of  a  red  corpuscle,  a  little  smaller 
or  a  little  larger,  with  clear,  rather  highly  refractive,  waxy-looking  proto- 


710 


THE  INFECTIOUS  DISEASES. 


I^lasm,  and  coarse  dark  pigment  granules,  wliicli  are  usually  collected  in  a 
ring  or  a  mass  in  the  center  of  the  organism.  The  granules  are  usually  very 
slightly  motile.  At  one  side  of  the  body  we  often  see  a  small  bib-like  attach- 
ment which  may  show  a  slightly  yellowish  color.  On  examination  this  proves 
to  be  the  remains  of  the  red  blood-corpuscles  in  which  the  organism  has  de- 
veloped. In  association  with  these  are  seen  crescentic  bodies,  the  proto- 
plasm of  which  shows  the  same  characteristics  as  that  in  the  forms  above 
described,  Avhile  the  pigment  is  collected  in  the  middle  in  a  similar  ring 
or  bunch,  and  is  but  slightly  motile.  On  the  concave  side  of  these  crescents 
one  may  also  often  see  a  bib-like  attachment,  just  as  in  the  ovoid  forms. 
At  times  during  the  examination  of  the  fresh  specimen  we  may  see  the 
change  from  an  ovoid  body  into  a  crescent  take  place.     The  development  of 


D...     1-2                               3                               4                               5                               6 

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*                                                                                                       i                                                                                                "sJ        "V 

Fig.  228. — ^4£stivo-autumnal  Fever  (mild  type).  Ushered  in  with  vomit- 
ing, restlessness  and  flushing.  The  spleen  is  enlarged.  Either  delirium  or 
drowsiness  and  somnolence  exists.      (Original.) 


these  forms  from  the  hyaline  bodies  can  be  followed  out  on  careful  ob- 
servation. They  are  thought  by  some  to  be  a  resting  stage  of  the  organism. 
Segmenting  bodies  are  almost  never  seen  in  the  circulating  blood  of  this 
form  of  malarial  fever,  though  the  presence  of  the  round  intracellular 
bodies  with  central  pigment  is  a  sure  sign  that  segmentation  is  going  on 
elsewhere.  It  has  been  found  by  the  Italians  that  after  the  accumulation 
of  a  few  pigment  granules  the  organisms  seek  the  internal  organs,  where 
segmentation  takes  place.  The  bodies  are  still  small  and  contained  within 
the  red  corpuscles.  The  pigment  gathers  in  the  center,  as  in  the  other  types 
of  segmentation,  while  the  segments  are  very  small  and  rarely  more  than 
twelve  in  number.  During  the  paroxysm  we  may  see  large  numbers  of  leu- 
cocytes containing  pigment  granules  and  clumps  which  are  probably  the 
remains  of  segmenting  organisms.  Flagellate  bodies  may  be  observed  here 
as  in  the  tertian  and  quartan  fevers,  but  only  when  ovoid  and  crescentic 
pigmented  bodies  are  present.    They  may  be  seen  to  develop  from  the  round 


MALARIAL    FEVER.  711 

bodies  with  central  pigment.  Careful  studies  concerning  the  morphological 
characteristics  of  the  malarial  parasite  have  shown  that  it  belongs  to  the 
class  of  protozoa,  and  is  possessed  of  a  nucleus  containing  one  or  more 
nucleoli.  At  the  time  of  sporullation  this  nucleus  divides — according  to 
some — directly,  according  to  others  by  karyokinesis." 

Pathology. — In  fatal  malaria  the  following  changes  are  found: — 

The  spleen  is  enlarged;  the  capsule  tense.  Death  has  been  reported 
from  rupture  of  the  spleen  (Thayer).  The  pulp  of  the  spleen  contains  large 
numbers  of  red  blood-corpuscles  in  which  the  characteristic  parasite  is 
found.  "The  capillaries  are  usually  filled  with  the  plasmodia,  while  the 
splenic  veins  show  relatively  few,  though  they  always  contain  large  cells 
enclosing  pigment  or  the  remains  of  red  corpuscles." 

The  Liver. — Small  areas  of  necrosis  are  described  by  Guarnieri:  "Nu- 
merous liver  cells  are  found  containing  clumps  of  hgematin  and  altered 
red  corpuscles,  a  condition  similar  to  that  found  in  pernicious  anasmia. 
Bignami  believes  that  this  may  explain  the  polycholia  found  in  cases  that 
died  of  pernicious  malaria." 

Examination  of  the  Blood. — A  small  drop  of  blood  should  be  taken 
from  the  ear  or  from  a  finger  tip.  The  usual  aseptic  precautions,  such  as 
carefully  washing  the  finger  with  soap  and  water,  followed  by  a  washing 
with  alcohol  or  ether,  should  be  strictly  carried  out.  Fresh  l^lood  must  be 
examined  soon  after  it  has  been  withdrawn — no  later  than  three  or  four 
hours.  A  film  of  blood  can  be  preserved  if  the  air  is  excluded  by  smearing 
vaseline  around  the  edges  of  the  cover  glass.  The  amoeboid  movements  of 
the  protozoa  can  be  studied  in  this  fresh  blood.  Blood  for  examination 
should  be  drawn  al)Out  one  hour  before  the  expected  paroxysin.  The  or- 
ganisms are  much  smaller  after  a  paroxysm. 

"The  tertian  parasite  completes  its  life  in  about  forty-eight  hours,  or 
less,  if  there  is  any  variation  from  tiiis  time.  In  the  first  twelve  hours  of 
their  life  the  parasites  appear  as  small,  clear  specks  (h3^aline  bodies)  in  the 
red  corpuscles,  and  if  any  pigment  is  to  be  seen  it  is  as  very  small  granules.' 
If  stained  they  appear  pale  blue.  They  are  actively  amoeboid,  and  remain 
so  for  about  an  hour  after  withdrawal.  In  the  next  twelve  hours  the  para- 
sites have  grown  to  about  one-third  the  size  of  the  corpuscle,  are  still 
amoeboid,  show  fine  granules,  and  the  corpuscle  has  become  paler.  In 
the  next  twelve  hours  the  parasites  have  taken  up  about  two-thirds  of  the 
cell,  have  become  less  amoeboid ;  the  granules  larger  and  moving.  The 
parasites  are  now  more  irregular  in  shape,  and  the  corpuscles  larger  and 
paler,  the  pigment  granules  standing  out  more  markedly.  In  the  next 
twelve  hours  all  motion  ceases,  the  corpuscles  become  shells,  the  centers 
of  which  are  occupied  by  the  parasites,  and  spore  formation  and  segmenta- 
tion begin.  The  organisms  break  up  into  fifteen  or  twenty  round  spores, 
at  first  contained  inside  the  cell-wall  of  the  red  corpuscles,  and  then  set  free 


712  THE  INFECTIOUS  DISEASES. 

into  the  blood.  It  is  at  this  time  that  the  clinical  paroxysm  occurs.  All 
hyaline  bodies  do  not  develop  to  the  stage  of  spore  formation,  nor  do  all 
these  spores — really  the  young  hyaline  bodies — which  have  been  set  free 
into  the  blood  serum  re-enter  the  red  corpuscles,  but  the  blood  plasma 
itself  destroys  numy  of  them. 

"Should  Ave  have  under  observation  clinically  a  quotidian  form  of 
malaria,  the  red  corpuscles  would  show  the  tertian  parasite  in  but  two  stages 
of  development,  one  group  being  approximately  tAventy-four  hours  older 
than  the  other ;  of  course,  depending  upon  the  hour  at  which  the  paroxysms 
occur.  This  is  due  to  a  double  infection.  It  must  not  be  forgotten,  however, 
that  we  may  have  a  triple  quartan  infection  that  produces  daily  paroxysms. 

"The  quartan  parasite  grows  in  seventy-tw^o  hours.  In  the  first  twelve 
hours  it  is  a  ver}^  small,  unpigmentcd,  slightly  amoeboid,  hyaline  body,  be- 
coming in  twelve  hours  more  about  the  size  of  one-sixth  to  one-fifth  that 
of  the  corpuscle,  having  taken  on  a  few  pigmented  granules  placed  peri- 
pherally. In  fortj^-eight  hours  it  is  one-half  to  two-thirds  the  size  of  the 
red  corpuscle,'  round,  as  a  rule,  and  possessing  no  amoeboid  movement.  In 
sixty  hours  from  the  paroxysm,  it  occupies  nearly  all  of  the  corpuscle, 
which  is  neither  enlarged  nor  paler  than  normal.  In  six  hours  more  the 
pigment  granules  approach  the  center  and  are  arranged  like  the  spokes  of 
a  wheel,  the  first  sign  of  segmentation.  About  three  hours  before  the  at- 
tack, segmentation  has  produced  from  six  to  ten  oval  or  pear-shaped  bodies 
or  spores  containing  pigment  in  their  centers.  In  multiple  infections  of 
this  type  we,  of  course,  find  the  organisms  in  the  blood  in  different  stages  of  j 
development.  Flagellated  bodies  develop  after  the  blood  is  removed  froi 
the  body,  and  consist  of  a  central  cell  with  arms  thrown  out.  These  arms 
are  freely  movable.  In  examining  a  fresh  specimen,  we  may  see  such  a' 
body  keeping  up  a  constant  ciliary  ihotion  and  causing  a  disturbance  in  the 
arrangement  of  the  red  cells  in  its  immediate  neighborhood.  The  flagellated 
body  does  not  often  appear  in  either  of  the  foregoing  types  of  the  infection, 
but  is  more  common  in  the  iTstivo-autumnal  variety.  The  second  group  of 
parasites  belongs  to  the  class  of  malignant  or  a^stivo-autumnal  figures,  and 
are  divided  into,  first,  the  pigmented  quotidian  parasite;  second,  the  un- 
pigmented  quotidian  parasite;    and  third,  the  malignant  tertian. 

"The  pigmented  quotidian  parasite  completes  its  cycle  in  twenty-four 
hours.  When  .seen  in  the  blood-corpuscle,  it  ap))ears  as  a  small  actively 
amoeboid,  hyaline  body,  rapidly  becoming  pigmented  and  quiet,  the  pigment 
lodging  in  the  periphery  of  the  organism,  after  which  it  breaks  up  into 
spores.  It  has  been  pointed  out  that  segmentation  of  this  type  does  not  take 
place  in  the  peripheral  l)lood.  but  occurs  in  the  spleen  and  bone  marrow. 
The  pigmented  organism  occupies  one-third  of  the  corpuscle  which  is 
shrunken,  if  clianged  at  all.  After  the  infection  has  lasted  for  several  days 
crescents  appear. 


MALARIAL    FEVER. 


713 


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714     ■  THE  INFECTlOrS  DISEASES. 

"Crescents  are  ahraijs  an  evidence  of  a'stivo-autuinnal  fever,  and  never 
occur  in  the  quartan  or  tertian  type.  They  are  from  eight  to  ten  niicro- 
nijlliineters  in  length  and  from  two  to  three  niicromillimeters  in  breadth, 
are  half-moon  shaped  when  typical,  but  vary  greatly,  oftentimes  appear- 
ing almost  straight.  They  contain  pigment  sometimes  scattered,  but 
oftener  found  clumped  in  the  center,  and  usually  without  motion.  With 
a  good  light  and  an  accurate  adjustment  the  shell  of  the  red  blood-cor- 
puscle can  be  seen  extending  from  the  poles  of  the  crescent,  showing  that 
this  parasite  is  distinctly  an  intracellular  formation.  Crescents  are  dis- 
tinctly an  evidence  that  the  infection  has  lasted  a  number  of  days, — five  or 
six — and  they  will  not  be  found  in  any  specimen  before  that  time.  The 
unpigmented  quotidian  parasite  shows  not  many  variations  from  the  fore- 
going type,  except  that  it  is  free  from  the  pigment,  though  the  crescents 
formed  from  this  variet}^  may  show  pigmentation.  The  malignant  tertian 
parasite  is  pigmented  and,  in  fact,  much  like  the  pigmented  quotidian.  It 
grows  to  segmentation  once  in  forty-eight  hours,  and  is  amoeboid  in  the  ad- 
vanced stage';  the  pigment  is  active  and  the  entire  organism  is  larger.  Prob- 
ably no  better  idea  can  be  given  concisely  of  the  different  characteristics  of 
these  parasites  than  by  reproducing  tlie  table  of  Mannaberg."     (See  p.  713). 

Symptoms. — In  very  young  chihlren  there  may  be  convulsions,  restless- 
ness, cold  extremities,  and  yawning.  The  pulse  is  full  and  rapid.  The  tem- 
perature may  reach  as  high  as  105°  F.,  or  even  higher.  After  this  febrile 
stage  the  body  is  covered  with  a  profuse  perspiration,  ending  in  sleep  from 
exhaustion.  Diarrhea  is  ocasionally  met  with  in  this  condition,  and  is  prob- 
ably the  result  of  secondary  infection.  Bronchitis  is  occasionally  seen.  The 
paroxysm  of  fever  occurs  when  the  protozoa  matures  and  begins  to  divide. 
This  process  repeats  itself  about  every  twenty-four  hours  in  the  tertian  type 
of  intermittent  fever  most  frequently  seen  in  this  country.  If  children 
are  carefully  observed,  then  the  onset  of  a  paroxysm  is  frequently  seen 
by  a  severe  cyanosis  affecting  the  nails.  This  would  correspond  to  the 
chill  seen  in  the  older  children.  Slight  albuminuria  or  hannaturia  fre- 
quently accompanies  malaria.  'I'here  is  no  disease  that  can  be  mistaken 
for  the  tertian  ty})e  of  malaria  when  it  is  remembered  that  there  is  a  sick 
day  with  fever,  etc.,  and  an  alternating  apparently  healthy  day. 

An  enlarged  spleen  is  usually  present. 

Diagnosis. — This  can  ])e  most  positively  made  by  an  examination  of 
the  blood.  So  many  symptoms  present  in  nuilaria,  such  as  lassitude,  pains 
in  the  bones,  headache  and  fever,  sinndate  other  diseases,  that  only  the  posi- 
tive finding  of  Laveran's  protozoa  in  the  blood  will  complete  the  diagnosis. 

Differential  Diagnosis. — If  there  is  a  doubt  as  to  the  differential  diag- 
nosis between  tuberculosis  and  malaria,  the  specific  effect  of  a  few  doses  of 
quinine  will  easily  show  the  presence  or  absence  of  malaria.  Tlie  blood  test 
is,  however,  conclusive. 


MALARIAL    FEVER.  715 

A  boy,  6  years  old,  was  brought  to  me  at  the  children's  service  of  the  Geimaii 
Poliklinik  with  a  history  of  headache,  fever,  and  pain  in  the  bones.  The  boy 
appeared  rather  icteric.  His  mother  said  that  he  had  lost  weight  during  the  last 
two  weeks.  He  perspired  freely,  had  a  good  day  and  a  bad  day.  The  fever  appeared 
in  the  afternoon.  The  examination  showed  a  well-nourished  boy,  lungs  normal,  a 
slight  hajmic  murmur  at  the  apex  of  the  heart  which  was  also  heard  in  the  vessels 
at  the  neck.  The  spleen  was  palpable  and  slightly  enlarged.  The  appetite  was  poor, 
the  bowels  moved  sluggishly.  The  child  was  restless  at  night.  The  examination 
of  the  blood  showed  the  presence  of  the  ordinary  tertian  parasite.  Quinine  in  3- 
grain  doses  was  given  every  four  hours,  and  G  grains  were  given  three  hours  before 
the  expected  attack,  which  in  this  condition  Avas  between  1  and  2  o'clock  in  the 
afternoon.  Fifteen  drops  of  cascara  sagrada  were  administered  before  breakfast 
of  each  day.  The  treatment  was  continued  for  ten  days.  The  boy  then  complained 
of  buzzing  in  the  ears,  evidently  due  to  cinchonism.  Quinine  was  given  every  second 
day  and  Fowler's  solution  in  S-drojj  doses  was  administered  on  alternate  days. 
Strengthening  food  was  given  and  the  child  made  a  complete  recovery.  Quinine  wa.s 
given  once  every  three  days  after  the  first  month.  The  child  took  an  ocean 
voyage  and  was  perfectly  well  in  two  months.  Iron  was  then  given  for  several 
months  as  a  tonic  and  the  treatment  discontinued. 

Prognosis. — This  is  usually  good.  If  malaria  is  neglected  severe  an- 
aemia follows,  and  if  pernicious  malaria  results  it  may  end  in  death.  In 
this  country  the  specific  effect  of  quinine  and  the  change  of  climate  usually 
gives  successful  results. 

Treatment. — A  patient  suffering  with  malaria  should,  if  possible,  be 
removed  to  a  different  climate.  A  change  from  the  city  to  the  country, 
or  vice  versa,  is  very  beneficial.  Next  in  importance  to  change  of  air  is 
the  specific  effect  of  quinine.  Five  grains  of  quinine  (0.3)  can  be  given 
to  a  child  3  years  old.  The  hydrochlorate  of  quinine  is  the  most  effective. 
Owing  to  its  disagreeable  taste  it  can  be  given  in  tablet  form,  after  which 
a  mouthful  of  coffee  or  chocolate  can  be  given.  When  quinine  is  refused 
by  mouth,  then  a  10-grain  dose  in  the  form  of  a  suppository  can  be  given 
three  times  a  day,  per  rectum.  TJte  best  time  for  administering  quinine  is 
about  three  hours  before  the  expected  attacl-.  The  bisulphate  of  quinine 
is  a  soluble  and  convenient  form  to  use.  It  is  very  important  to  keep  the 
bowels  open  and  tlie  kidneys  active.  Fifteen  to  30  drops  of  fluid  extract 
of  cascara  sagrada  can  be  given  in  a  palatable  menstruum  every  morning, 
so  that  the  action  of  the  bowel  is  assisted.  In  true  malaria,  I  have  found 
especial  benefit  in  administering  whisky  well  diluted  with  water,  or  given 
in  milk.  Apart  from  its  nutritive  properties,  it  certainly  has  decided  anti- 
septic properties.  If  malaria  persists  in  spite  of  continued  treatment,  then 
arsenious  acid  in  doses  of  '/,„„  or  Vir.o  grain,  can  be  administered  three 
times  a  day.  Fowler's  solution,  in  doses  of  1  to  5  drops,  should  not  be 
forgotten.  Jaeobi  recommends  ergot  in  doses  of  20  to  .50  drops  every  day 
for  weeks.  \Then  it  is  not  well  l)orne  he  combines  it  with  (piinine  or  arsenic. 
I  have  never  been  able  to  see  the  slightest  benefit  from  the  use  of  ergot, 
although  I  have  tried  it  in  many  cases.  I  believe  Jacobi's  results  were  good 
when  he  combined  the  ergot  ^ith  the  quinine  because  the  quinine  was  given. 


CHAPTEE  XVI. 

SYPHILIS. 

Tins  is  a  specific  disease  most  probably  cnnsed  by  the  invasion  of  a 
micro-organism.  The  disease  in  infancy  is  tlie  same  as  tliat  iiound  in  adults. 
There  are  two  forms  of  the  disease : — 

1.  Inherited  syphilis. 

2.  Acquired  syphilis. 

Etiology. — The  most  frequent  modes  of  infection  are: — 
By  nursing  from  the  breast  of  a  syphilitic  wet-nurse. 
Eating  from  the  dishes  of  syphilitic  patients. 
Unclean  surgical  instruments;  for  example,  when  an  infant  is  vac- 
cinated, or  during  the  operation  of  circumcision. 

The  Transmission  of  Syphilis  in  Utero. — An  infant  in  utero  may  be 
infected  directly  through  the  circulation  in  the  placenta.  If  the  mother 
acquires  syphilis  during  the  ninth  month  of  her  pregnancy,  the  same  will 
not  infect  her  child  nor  modify  its  development.  A  healthy  infant  in 
utero  can  be  infected  by  passing  through  a  syphilitic  genital  tract  of  its 
mother  during  labor. 

When  the  ovum  is  infected  with  syphilis,  which  frequently  happens 
at  the  time  of  conception,  it  may  terminate  in  the  death  of  the  foetus,  re- 
sulting in  an  abortion  or  in  the  birth  of  a  still-born  child.  If  the  child 
lives  it  may  suffer  with  cachexia,  and  a  few  weeks  later  present  the  char- 
acteristic skin-lesions.  The  father  can  infect  the  mother  for  three  or,  at 
the  most,  five  years  after  his  chancre.  The  father  may  infect  the  foetus  as 
late  as  twenty  years  after  his  chancre,  when  for  years  he  has  presented  no 
signs  of  syphilis.  The  mother  may  have  a  series  of  syphilitic  pregnancies 
resulting  in  miscarriages  or  in  syphilitic  infants,  without  at  any  time 
herself  presenting  any  syphilitic  manifestations.  In  the  same  couple  the 
severity  of  the  infection  transmitted  to  the  foetus  tends  to  decrease  with 
succeeding  pregnancies.  Thus  it  is  the  rule  for  the  mother  to  have  at 
first  several  abortions,  then  a  child  born  dead,  and  finally  a  living  child 
showing  the  evidences,  of  inherited  syphilis.  Children  born  later  usually 
suffer  less  severely,  but  this  "law  of  decreases"  (Diday)  is  not  without  nu- 
merous exceptions;  sometimes  the  third  or  fourth  child  suffers  more  than 
the  second.  In  other  families  children  of  one  sex  suffer  more  than  those 
of  the  opposite  sex.  In  twin  pregnancies  one  may  be  affected  while  the 
other  apparently  escapes.  The  apparent  escape  of  the  mother  of  syphilitic 
infants  by  a  syphilitic  father  has  been  accounted  for  on  the  supposition 
(716) 


{ 


SYPHILIS.  717 

that  she  uEclergoes  a  mitigated  infection  derived  from  tlie  foetus.  Coutts^ 
has  pointed  out  the  theory  that  she  absorbs  from  the  foetus  a  syphilitic  anti- 
toxin; this  would  account  not  only  for  her  apparent  immunity,  but  also  for 
the  gradual  decrease  in  the  severity  of  the  disease  in  later  pregnancies.  If 
the  mother  be  infected  but  not  the  father,  death  of  the  fcetus  is  the  most 
likely  result.  If  the  child  is  born  alive  it  will  probably  suffer  from  in- 
herited syphilis.  If  both  parents  have  suffered  from  manifest  syphilis,  the 
chance  of  abortion  or  still-birth  is  greater. 

Colles's  Late. — In  1837  Colics  wrote  that  "A  new-born  child  affected 
with  inherited  syphilis,  even  though  it  may  have  the  specific  lesions  in  the 
mouth,  never  causes  infection  of  the  breast  which  it  sucks  if  it  be  the  mother 
who  nurses  it,  although  continuing  capable  of  infecting  a  strange  nurse." 
The  substantial  truth  of  this  dictum  has  not  been  seriously  questioned, 
though  various  exj)lanations  have  been  offered. 

Is  Inherited  Syphilis  Contagious? — The  following  interesting  conclu- 
sions are  based  upon  Robert  W.  Parker's  twenty  years'  experience  in 
the  East  London  Children's  Hospital : — 

1.  The  children  of  S3'philitic  parents  very  frequently  show  manifesta- 
tions of  a  disease  which  is  almost  universally  called  "inherited  syphilis." 

2.  In  a  large  proportion  of  the  cases  this  inherited  disease  is  not 
syphilis  at  all,  in  that  the  disease  is  non-contagious,  and  would  be  better 
named  "inherited  from  syphilis." 

3.  This  inherited  syphilis  is  true  syphilis  only  if  it  conform  to  the 
ordinary  tests  which  pertain  to  contact  syphilis,  and  prove  to  be  infectious 
and  contagious. 

4.  The  children  of  syphilitic  parents  occasionally  inherit  syphilis. 

5.  The  mother  suckling  a  child  with  such  a  disease  mav  be  infected 
by  it. 

G.  A  healthy  wet-nurse  and  other  persons  brought  into  contact  with 
such  a  child  are  even  more  liable  to  be  infected  by  it  than  the  mother. 

7.  Lymph  taken  from  such  a  child,  even  although  apparently  well  at 
the  time,  will  probably,  or  possibly,  invaccinate  syphilis. 

8.  In  reply  to  the  question:  "Can  a  healthy  woman  give  birth  to  a 
syphilitic  child  ?"   the  answer  must  be  "Xo." 

9.  Many  women  give  birth  to  children  who  suffer  from  what  is  called 
"inherited  syphilis,"  without  themselves  appearing  to  be  infected.  The 
explanation  is  obvious:  this  "inherited  syphilis"  is  not  syphilis  in  the  true 
sense,  and  the  mother's  so-called  escape  depends  upon  this  fact. 

10.  There  is  no  recent  clinical  evidence  which  fully  realizes  Colles's 
teaching,  viz.:  a  mother  suckling  her  own  syphilitic  infant  and  escaping 
an  infection  to  which  a  healthy  wet-nurse  suckling  the  same  infant,  and 


*  ''Some  Aspects  of  Infantile  Syphilis."     lluntorian  Lectures,  London,  1807. 


718  THE  INFECTIOUS  DISEASES. 

other  members  of  lier  family  who  liave  niercl}-  liandlod  this  infant,  have 
succumbed,  the  hitter  facts  being  essential  if  only  to  establish  the  contagi- 
ousness of  the  infant's  disease  in  any  and  every  given  case  asserted  to  be 
"inherited  syphilis." 

Pathological  Anatomy. — In  acquired  syphilis  changes  are  the  same  in 
the  child  as  in  the  adult. 

In  hereditary  syphilis  there  are  certain  constant  changes  present  in 
the  bones.  These  changes  are  confined  to  the  shafts  of  the  long  bones  and 
to  the  cranial  bones. 


Fig.  229. —  (A)  Spirochsete  Pallida;  (B)  Spiroohgete  Refringens  from  a 
case  of  Syphilis.  First  described  by  Schaudiim  and  Ilofi'mann  in  Berlin  in 
May,  1905.  There  is  no  question  bnt  that  the  above  parasites  are  the 
causative  agents  of  syphilis.  This  specimen  was  obtained  through  the  kind- 
ness of  Dr.  Boas,  of  Berlin.      (Original.) 

The  pathological  clumges  are  not  confined  to  the  epiphyses,  but  the 
diaphyses  are  also  swollen.  The  ends  of  tlie  bones  are  swollen.  The  inner 
portion  of  the  periosteum  shows  swelling  and  hyperemia. 

Tlie  circulatory  apparatus  shows  tliickening  of  tlie  arterial  walls  as 
well  as  of  the  veins.  Owing  to  this  degeneration  there  is  a  tendency  to 
bleeding.      (See  clinical  case  described  in  this  chapter.) 

Catarrhal  manifestations  showing  implication  of  the  respiratory  tract> 


SYPHILIS.  719 

and  also  the  gastro-intestinal  tract,  can  be  noted.  The  liver,  spleen,  and 
pancreas  are  enlarged. 

The  lymph  glands  of  the  entire  body  are  enlarged. 

Symptoms. — When  catarrh  is  troublesome  in  children  and  not  amen- 
able to  ordinary  treatment,  syphilis  should  be  suspected.  It  is  surprising 
to  find  the  frequency  with  which  nasal  and  nasopharyngeal  catarrh  is  asso- 
ciated with  syphilis.  I  have  not  yet  had  occasion  to  regret  asking  a  direct 
question  of  a  parent  in  whom  I  suspected  syphilis,  if  such  parent  is  told 
that  we  must  know  his  previous  history,  for  the  benefit  of  his  child. 

Gastro-intestinal  Tract. — The  gastro-intestinal  tract  is  the  one  that 
will  frequently  show  the  manifestations  of  syphilis.  An  infant  will  not 
appear  to  thrive  nor  will  it  digest,  in  spite  of  the  most  careful  dietetic  meas- 
ures. Syphilitic  lesions  of  the  liver,  pancreas,  stomach,  and  intestine  are 
simply  all  part  of  the  infection.  Anti-luetic  treatment  will  frequently  do 
more  good  in  a  few  days  or  weeks  than  months  of  rigid  diet.  Thus  it  is 
apparent  that  in  order  to  do  good  in  tliis  disease  we  must  seek  to  remove 
tlic  cause. 

When  a  persistent  diarrhoea  will  not  respond  to  the  ordinary  treat- 
ment of  careful  diet  and  medication,  then  suspect  syphilis.  When  diar- 
rhcea  such  as  a  mucus-colitis  persists  without  fever  after  careful  dieting, 
then  syphilis  may  be  suspected. 

The  following  case  will  illustrate  congenital  syphilis: — 

An  infant  about  one  ireek  old  was  seen  bii  vie.  It  was  the  fourth  child  of 
apparently  healthy  parents.  Three  children  had  previously  die^l,  and  this  fourth 
child  was  born  at  full  term.  The  mother  noticed  that  the  child  cried  incessantly  and 
was  very  restless.  The  child  had  had  sniffles  since  birth.  It  was  breast-fed  and 
appeared  to  sufler  Avitli  colic  and  hunger.  Tlie  stools  were  gi"ass-green  and  con- 
tained mucus  and  curds.  The  palms  and  soles  had  a  pemphigus.  The  skin  had  a 
yelloAvish  tinge.  The  nose  was  excoriated  from  the  discharge.  The  anus  had  deep 
cracks — the  so-called  rliagades.  Around  tlie  mouth  were  also  rhagades.  The 
spleen  was  enlarged  and  palpable.  The  lymph  glands  were  not  enlargefl.  The  chill 
did  not  seem  to  thrive.  The  finger  nails  showed  distinct  evidences  of  the  disease. 
The  bones  of  the  fingers  and  toes  sliowed  the  presence  of  dactylitis  syphilitica.  The 
diagnosis  of  congenital  syphilis  was  made.  The  mother  had  plenty  of  milk,  but 
was  compelled  to  wean  the  child  owing  to  a  typhoidal  condition  to  which  she  suc- 
cumbed. The  infant  was  bottle-fed,  and  when  about  five  weeks  old  d('velo])e<l  a  large 
abscess  on  the  forearm  which  was  incised  under  an  anaesthetic  by  Dr.  Geo.  F.  Sliraily. 
One  week  later  a  series  of  metastatic  abscesses  formed  over  the  abdomen  and  on 
the  back.  The  child  died  from  inanition  and  general  sepsis  when  about  nine  weeks 
old. 

IlcemorrJiages  from  the  nose  and  mouth,  and  bloody  stools  due  to  ulcer- 
ation of  the  intestinal  tract  are  frequently  reported. 

Uracek  has  reported  hjicmorrhages  in  the  different  internal  organs 
caused  by  syphilis  in  the  infant.  TTmbilical  haMnorrhages  are  sometimes 
due  to  syphilis,  according  to  Rotch, 


720  '-I'HE  INFECTIOrS  DISEASES. 

The  following  case  will  illustrate  hlocding  in  the  new-born: — 

An  infant  sxiflercd  with  a  severe  furiii  of  iiiarasiiuis  and  athrcpsia.  It  did  not 
develop.  Examination  of  the  niueous  membrane  of  its  nioiitli,  gums,  and  fauci'S 
showed  distinct  i)atehes.  Tlic  child  was  attended  b}'  Dr.  Honor,  of  New  York  City, 
who  referred  the  ca.se  to  Dr.  W.  Freudenthal  for  diagnosis.  The  case  was  also  seen 
by  me  and  I  concurred  in  the  opinion  expressed,  that  the  patches  were  non- 
diphtheritic  and  were  most  likely  due  to  syphilis.  Several  days  later  Dr.  Freudenthal 
and  mjself  were  again  called  to  see  this  child  owing  to  an  extensive  nasal  haemor- 
rhage. In  spite  of  the  most  active  local  treatment,  the  use  of  haemostatics,  such,  as 
adrenalin,  and  tlie  use  of  styptics  internally  and  externally,  the  infant  died  from 
exhaustion.  The  attending  physician,  Dr.  Honor,  subsequently  stated  that  he  had 
found  distinct  evidence  of  syphilis. 

Frequently  the  diagnosis  must  be  made  by  a  process  of  exclusion.  This 
is  especially  true  when  children  will  not  thrive  and  the  physician  cannot 
get  a  true  family  history  from  the  father  and  mother,  as  in  one  instance 
known  to  me,  where  the  father  was  a  traveling  man. 

.  Sl-in  Lesions. — The  skin  lesions  develop  soon  after  those  of  the  mu- 
cous membrane.  The  eruption  consists  of  small,  round,  pink  macules,  which 
disappear  on  pressure.  While  the  eruption  may  be  on  the  abdomen  and 
lower  limbs,  it  not  infrequently  is  found  all  over  the  body.  At  times  the 
eruption  resembles  an  erythema  and  is  copper-colored.  Sometimes  the 
eruption  is  papular;  it  is  not  infrequent  to  find  condylomata  around  the 
mouth  or  anus.  These  condylomata  are  very  contagious.  Pustules  .are 
frequently  seen  as  early  as  two  months;  sometimes  later.  This  eruption 
can  usually  be  differentiated  from  eczema  by  the  characteristic  absence  of 
itching  that  always  accompanies  eczema.  Furuncles  are  usually  found  in 
poorly  nourished  children.  The  infant  usually  has  the  appearance  of  a 
shriveled  old  man. 

Specific  Laryngeal  Stenosis.- — By  this  is  meant  laryngeal  stenosis 
found  in  syphilitic  children,  and  which  is  always  congenital.  Such  cases 
are  very  uncommon  and  will  tax  the  skill  of  many  physicians. 

A  case  of  this  kind  was  seen  by  me  several  years  ago;  an  infant  seven  months 
old  was  brought  to  my  clinic  with  a  history  of  difficult  breathing,  restlessness,  in- 
somnia, cough,  and  retarded  development.  The  child  was  nursing  at  the  breast.  Its 
body,  the  arms  and  legs,  chiefly  the  face,  the  lips  and  the  finger  nails,  were  bluish; 
in  fact,  the  child  was  in  a  condition  of  general  cyanosis.  The  temperature  of  the 
child  was  normal,  the  pulse  ranged  from  1.54  to  164;  it  was  small  and  feeble  in 
character.  The  heart-sounds  were  dull ;  there  was  a  blowing  presystolic  murmur, 
which  was  transmitted  and  could  be  heard  with  great  distinctness  in  the  vessels 
of  the  neck.  It  was  looked  upon  as  hsemic  in  character.  An  examination  of  the 
lungs  gave  on  auscultation  loud  sonorous  rales,  which  at  times  disappeared  and  gave 
place  to  normal  vesicular  breathing.  There  was  no  expectoration.  The  child  had  a 
short,  explosive  cough  several  times  in  a  minute,  which  on  expiration  gave  a  j)eculiar 
croupy  sound,  and  on  inspiration  made  a  loud,  rattling,  rough  sound.  That  a  con- 
stant irritation  was  present,  was  shown  by  the  fact  that  the  child  had  paroxysms  of 
cough  which  did  not  abate  night  or  day,  and  Avas  not  relieved  by  lying  on  the  side. 


SYPHILIS.  721 

lying  on  the  back,  or  by  the  child  being  held  in  a  sitting  position,  or  by  traction  on 
the  tongue.  The  stomach  seemed  to  be  in  a  fair  condition,  although  there  was  occa- 
sional vomiting.  The  stools  were  yellowish  (mustard-like)  in  character  and  seemed 
to  be  thoroughly  well  digested.  From  the  history  of  the  cliild's  mother  I  learned 
that  from  the  first  day  after  birth  the  cough  had  been  present,  which  had  con- 
tinually grown  worse,  and  at  the  time  of  writing  was  so  bad  that  the  mother  de- 
termined to  have  it  operated  upon  if  necessary.  Several  attempts  at  a  laryngoscopic 
examination  were  made,  but  these  were  all  ineffectual  in  spite  of  a  thorough  cocain- 
ization  of  the  parts.  On  introducing  the  finger  nothing  abnormal  could  be  felt.  The 
case  was  referred  to  Dr.  C.  G.  Rice,  and  he  agreed  v.'ith  me  that  we  were  dealing  with 
a  case  of  sub-glottic  stenosis,  which  could  only  be  relieved  by  a  tracheotomy.  Before 
the  case  was  referred  to  several  colleagues  for  their  opinion,  the  diagnosis  of  syphilis 
had  been  made.  The  mother  of  the  child  stated  that  she  had  had  several  miscarriages 
and  one  prematurely  born  baby.  The  medicinal  treatment  consisted  of  calomel  fumi- 
gations morning  and  evening  at  intervals  of  twelve  hours,  beside  inunctions  of  mer- 
curial ointment  and  calomel  internally.  The  child  was  also  seen  by  Dr.  W.  Freuden- 
thal,  who  concurred  in  the  diagnosis  of  "congenital-syphilitic  sub-glottic  stenosis  of 
the  larynx."  It  was  very  evident  that  the  stenosis  was  too  far  down  to  be  benefited 
by  an  intubation  tube  and  thus  it  was  referred  for  a  deep  tracheotomy  to  Dr.  Beck 
at  the  St.  Mark's  Hospital. 

lite  Teeth. — The  teeth  in  congenital  syphilis,  instead  of  appearing  at 
tlie  sixth  or  seventh  month,  may  not  appear  until  the  fourteenth  or  fif- 
teenth month,  and  even  later.    These  teeth  are  usually  carious. 

Congenital  Syphilitic  or  Hutchinson's  Teeth. — This  variety  of  dental 
abnormality  is  important,  because  as  Hutchinson  says,  "It  is,  if  talcen 
alone,  by  far  the  most  valuable  of  the  signs  by  which  we  recognize  in 
adolescence  tlie  effect  of  inherited  syphilis."  The  characteristics  of  these 
teeth  are  not  sufficiently  known,  and  abnormal  and  peculiar  teeth  of  other 
kinds  are  often  erroneously  regarded  as  proofs  of  congenital  syphilis.  The 
main  points  about  "Hutchinson's  teeth"  are  as  follows : — 

1.  It  is  always  the  permanent  teeth  which  are  affected.  The  tem- 
porary teeth  in  syphilitic  infants  often  decay  early,  but  they  present  no 
special  peculiarities  of  form. 

2.  The  only  teeth  which  afford  incontestable  evidence  of  congenital 
syphilis  are  the  upper  central  incisors.  The  first  molars,  the  other  incisors, 
and  canines  often  afford  corroborative  evidence,  but  they  are  never  to  be 
trusted  alone. 

3.  The  characteristic  peculiarities  which  distinguish  these  central 
incisors  are  as  follows:  They  are  dwarfed,  being  too  short  and  too  narrow; 
and  sometimes  the  portion  of  the  upper  jaw  from  which  they  grow  is  also 
arrested  in  growth.  They  often  stand  somewhat  apart  and  slope  toward 
one  another.  They  arc  unusually  rounded  on  section;  they  arc  "pegged" 
(that  is  to  say,  the  teeth  are  broader  at  the  gum  than  at  the  free  edge), 
and  they  are  notched.  The  notch  is  usually  shallow  and  the  dentine  is 
exposed  at  the  bottom  of  it.  It  is  formed  by  the  breaking  away  of  the 
imperfectly  developed  central  i)ortion  of  tlie  edge.    The  teeth  are  generally 


(22 


TllK   IXFECTIOLS  DISEASES. 


Fig.  230. 


Fie.  231. 


Fig.  232. 


Fiff.  233. 


Figs.  230,  231,  232,  233.— Syphilitic  Teeth.  Various  types  of  hereditary 
sypliilitic  teeth,  as  described  by  Hutchinson,  also  parenchymatous  keratitis. 
Note  that  the  upper  central  incisors  show  the  positive  evidence  of  syphilis. 
(Courtesy  of  Dr.  Hugo  Neumann.) 


,SVP111L1«. 


•23 


not  of  a  good  color,  and  they  are  abnormally  soft,  so  that  by  the  time  the 
patient  is  20  they  may  be  ground  down  like  those  of  an  old  man. 

The  fir^t  molars  arc  next  in  diagnostic  importance  to  the  up})er  cen- 
tral incisors.  When  charactei'istic  they  are  spoken  of  as  "dome-topped"' 
Their  sides  slope  toward  the  center  over  which  the  enamel  is  defective.  As 
might  be  expected,  syphilitic  teeth  not  infrequently  present  the  character- 
istics of  mercurial  teeth  in  addition  to  their  own  jieculiarities. 

Diagnosis  and  Differential  Diagnosis.^ — Tlie  clinical  history  will  lie  the 
guide  in  congenital  syjihilis.  The  history  of  ])revious  abortions  and  still- 
born children  will  aid  in  estalilishing  a  diagnosis. 

The  cachectic  skin,  the  wrinkled  mouth,  and  rhagades  at  both  mouth 
and  anus  will  materially  aid  in  establishing  a  diagnosis. 

At  times  pseudo-paralysis  will  be  present ;  sometimes  coryza,  hoarse- 
ness, inflamed  eyes,  and  persistent  I'unning  ears.  Such  children  do  not 
thrive,  but  appear  at  a  standstill  in  tlu^ir  development. 

Tlie  }Va>iS('rnian  Reaction. — Tn  sus])iciinis  cases  the  blood  should  ])e 
examined  to  see  if  we  get  a  positive  Wasserman  reaction. 


T.vni.E  No.  0.5. — Diffcreiilia}  I'ointu  Bctirroi  l^i/pJiilis  mid  Ttiherriilosi.-i. 

( ]\Iorrow. ) 

SYPHILIS.  TUBERCULOSIS. 

Exhibits  a  marked  predilection  for  the  Is    almost   exclusively    situated   in   the 

long   bones;     its   habitual    localization   is  epii^hysis,  rarely  afi'ecting  the  shaft, 
in   the   diaphysis   and   almost  always   at 
its  terminal  extremity. 

Theie  is  a  marketl  enlargement  of  the  The  tumefaction  is  due  less  to  increase 

bone  by  more  or  less  voluminous  osseous  in  the  size  of  the  bone  than  to  (edcmatims 

tumors  or  hyperostoses,  -with  little  or  no  infiltration  of  the  soft  structures, 
involvement  of  the  soft  ])arts. 

There  is  liltie  tendency  to  su]i])uralion  The  ])yogenic  tendency  is  nnuked. 
and  necrosis. 

Osteocopic     ]>ains     with      tendency     to  The  |)ain  is  dull  and  lieavy.  not  aggra- 

nocturnal     exacerbation     are     inonounced  vatcd    at   niglil:     sometimes   there    is   en- 


features. 

The  osseous  lesions  rai'ely   react   upon 
the   general    system. 


Tn  daclxlitis  there  is  little  involvement 


tire  absence  of  acute  painful  symjitoms. 

Tlie  osseous  lesions  often  det('rmin(>  a 
marked  impairment  of  the  general 
liealth.  grave  complications,  iiectic  fever, 
cachexia,  etc. 

Tn  dactylitis  the  swelling  is  due  more 
of  the  soft  parts,  the  swelling  being  to  an  tedenrntous  infdtrated  condition  of 
caused  by  the  enlargement  in  the  size  of  the  soft  tissues  than  to  enlargenuMit  of 
the  bone.  the  bone.     Breaking-down  of  the  tissues 

and  ulceration  are  more  apt  to  ensue. 


1  See  ''Blofxl   in  Syjihilis."  ])age  72S. 


724 


THE  INFECTIOUS  DISEASES. 


"The  diagnosis  between  syphilis  and  rachitic  bone  lesions  may  become 
of  great  importance.  Epiphyseal  swellings  occurring  under  six  months  are 
apt  to  be  syphilitic.  In  syphilis  the  epiphyseal  swelling  may  be  unilateral, 
but  it  is  always  symmetric  in  rachitis.  In  doubtful  cases  the  swelling  must 
be  subjected  to  specific  treatment.  It  is  well  to  remember,  however,  that 
rickets  and  syphilis  may  co-exist  in  the  same  case.  There  is  almost  in- 
variably enlargement  at  the  costochondral  articulations  in  all  cases  of 
rickets,  which  is  absent  in  syphilis." 

Table  No.  »(>. — Diffciriitid}  I'nints  Between  Syphilitic  and  Scrofulous  Lesions. 

(Morrow.) 


SYPHILITIC     LESIONS. 

General  in  tlieir  distribution,  they  oc- 
cur iijjon  any  region  of  tlie  body. 


Are  ambulatory  and  changing;  tliey 
disappear  and  reappear  elsewhere. 

The  color  is  reddish-brown,  or  "lean- 
liaiii"  tint. 

Jn  the  initial  stage  the  neojjlasms  are 
firm  and  hard. 

In  the  ulcerative  stage  the  ulcers  are 
cleaner  cut,  regular  in  contour,  with  per- 
pendicular, firmly  infiltrated  border  en- 
circled by  a  pigmented  areola. 

The  crusts  are  bulkier,  thicker,  with 
a  tendency  to  accumulate  in  layers,  and 
darker  in  color. 

The  cicatrices  are  smooth  and  remain 
long  surrounded  by  a  pigmented  areola. 


The  course  of  the  ulcer  is  sluggish  and 
dironic. 


SCROFULOUS   LESIONS. 

Limited  in  their  localization:  they 
have  a  special  predilection  for  the  neck 
or  regions  rich  in   lymphatic  glands. 

Are  fixed  and  permanent. 

The  color  is  brighter  and  more  viola- 
ceous in  hue. 

In  the  initial  stage  the  neoplasms  are 
softer  and  more  compressible. 

The  ulcers  are  irregular,  with  soft,  un- 
dermined borders;  they  are  painless, 
bleed  easily,  and  show  slight  tendency  to 
spread. 

The  crusts  are  softer,  more  adherent. 


The  cicatrices  are  elevated,  irregular, 
bridled;  they  retain  their  violaceous 
color  for  a  long  time. 

The  course  of  the  ulcer  is  more  slug- 
gish. 


"The  absence  of  pain  and  local  reaction  characterize  both  syphilitic 
and  scrofulous  ulcers;  they  are . essentially  lesions  without  sensory  symp- 
toms." 

Prognosis. — This  depends  upon  the  condition  of  the  child  at  the  time 
treatment  is  commenced.  It  must  be  remembered  that  such  children  have 
very  little  or  no  vitality.  Hence  they  succumb  very  easily  to  the  effects 
of  exhaustion  and  inanition. 

Hereditary  syphilis  can  be  transmitted  to  healthy  children.  So  that 
the  precaution  of  strict  isolation  should  ])e  remembered. 


SYPHILIS.  725 

Treatment. — Heroic  treatment  can  be  instituted,  even  though  tlie  child 
may  appear  to  have  little  vitality.  It  is  surprising  to  note  the  drug  toler- 
ance of  these  children  when  mercury  is  given. 

Local  Treatment. — The  safest  method  of  administering  mercury  is 
in  the  form  of  bichloride  baths.  These  baths  can  be  given  in  a  wooden 
tub,  in  which  enough  water  is  drawn  to  cover  the  child's  body.  From  5 
to  lU  grains  of  bichloride  can  be  added  to  this  tub  of  water.  Infants  up  to 
1  year  can  be  bathed  from  ten  to  twenty  minutes  every  day. 

The  presence  of  eczematous  or  other  skin  eruptions  would  not  contra- 
indicate  giving  these  baths. 

The  inunction  of  chemically  })ure  mercurial  ointment  well  rul)bod  into 
the  axilla*,  knee-joints,  or  the  thighs  will  materially  aid  in  bringing  this 
drug  into  the  system. 

For  the  relief  of  syphilitic  warts  nothing  is  better  than : — - 

IJ  Bichloride    10  parts 

Alcohol 100  parts 

Apply  with  absorbent  cotton  several  times  a  day. 

Internal  Treatment. — Internally  calomel  and  bichloride  or  the  tannate 
of  mercury  can  be  given  in  suitable  doses.  It  is  advisable  to  give  the  child 
from  1  to  5  grains  of  iodide  of  sodium,  according  to  age,  to  alternate  with 
the  mercurial  treatment. 

Care  should  be  taken  that  stomatitis  is  not  developed  in  nurslings.  If, 
however,  stomatitis  has  developed,  then  active  and  persistent  treatment  with 
chlorate  of  potash  solution,  locally,  will  be  found  effectual. 

It  is  self-understood  that  hygienic  treatment  in  addition  to  careful 
diet  is  just  as  important  as  the  specific  drug  treatment. 

Feeding. — A  diet  of  milk,  eggs,  cereals,  fish,  and  fruit  should  form  the 
basis  of  nutrition.  The  reader  is  referred  to  tlie  chapters  on  "i\rarasmus" 
and  "Kickets"  as  a  guide  to  the  method  of  feeding  necessary  to  reconstruct 
a  weakened  child. 


PAET  VIII. 

DISEASES  OF  THE  BLOOD,  GLANDS  OR  LYMPH  NODES, 
AND  DUCTLESS  GLANDS. 


CHAPTEE  I. 
INTRODUCTORY. 


The  Blood.^ 
The  red  corpuscles  (also  known  as  the  erythrocytes).  The  red  cor- 
puscles of  the  blood  are  more  numerous  at  birth  than  in  later  life.  Hayem 
and  Helot  found  that  when  the  umbilical  cord  was  not  tied  until  its  pulsa- 
tions ceased,  a  greater  number  of  red  corpuscles  were  found  than  in  cases 
where  immediate  ligation  was  performed.  Leder  and  Hutchinson,  com- 
paring the  new  infant's  blood  with  that  of  its  mother,  found  that  the  blood 
of  the  infant  contained  a  larger  number  of  red  corpuscles.  The  following 
table  will  show  the  difference  in  blood  count  by  various  writers : — 

Table  No.  07. 

Hayem   averaged  5,360,000 

Sorensen   "  5,6fi.5.000 

Otto "  6.165,000 

Boucliat  and  Dubrisay   "  4,300,000 

Schiff  (one  case) "  ((,658,000 

Gundobin   "  6,700,000 

Elder  and  Hutchinson : '■'  5,346,560 

Schwinge  greatest  at  birth. 

The  difference  varies  between  ;350,()00  and  500,000  per  culjic  milli- 
meter. Gundobin  believed  that  the  concentration  of  the  blood  was  caused 
by  loss  of  water  through  the  lungs.  Schiff  found  the  same  condition;  he 
also  states  that  the  number  of  corpuscles  decreases  when  the  child  is  put  to 
the  breast.  The  number  of  red  corpuscles  begins  to  fall  after  the  second 
day. 

In  one  case  Schiff  studied  the  number  in  the  morning  and  evening 
during  the  first  fifteen  days  of  life;  he  found  the  number  declined  irregu- 
larly. The  first  day's  count  was  7.628,000 ;  tlie  last  day's  count  was  4,505,- 
GOO;   the  average  for  the  fifteen  days  was  5,828,465. 

According  to  Schwinger  and  Gundobin  there  is  a  decrease  in  the  num- 
ber during  the  first  year,  after  this  there  is  an  increa.se  up  to  the  eighth  or 

*I  am  indebted  to  Stengel  and  Wliitc.  Arcliivcs  of  Pediatrics,  April,  1901,  for 
many  valuable  points  in  the  preparation  of  this  article- 

(726) 


THE    BLOOD.  727 

twelfth  year,  when  the  number  becomes  approximately  that  of  adult  life. 
Sex  makes  no  difference  in  the  count  of  the  red  corpuscles  in  infancy. 

Size. — The  red  corpuscles  vary  greatly  in  size  at  birth  and  during  the 
first  few  days  of  life.  Hayem  found  variations  between  3.25  //.  to  10.25  fx 
and  Loos  found  the  size  varying  from  3.3  ju,  to  10.3  fj..  Guudobin  claims 
that  the  haemoglobin  is  more  firmly  attached  to  the  cell  stroma  iu  the  new- 
born infant.  He  also  calls  attention  to  the  great  number  of  small-sized 
corpuscles. 

The  Hcemoyhhin. — According  to  Morse,  Elder,  Hutchinson,  Taylor, 
and  Rotch,  haemoglobin  is  increased  at  birth,  but  the  percentage  declines 
rapidly  during  the  first  few  days  of  life.  According  to  Kieder  there  is  an 
excess  of  25  to  30  per  cent,  at  birth  compared  with  infants  after  feeding 
has  begun. 

Specific  Gravity. — This  varies  just  like  the  haemoglobin.  At  birth  the 
specific  gravity  is  high. 

Monti  found  the  specific  gravity  at  birth 1060 

Rotch  found  the  sjiecific  gravity  at  birth 1065 

Hoch  &  Schlessinger  found  the  specific  gravity  at  birtli 1066 

Moelle  found  the  specific  gravity  at  birtli 1060 

The  specific  gravity  may  not  vary  for  weeks  or  months  in  healthy 
children. 

The  White  Blood  Corpuscles  (Leucocytes). — Leucocytes  are  found  in 
greater  number  at  birth  than  in  later  life.  'J'his  excess  in  number  has  fre- 
quently been  spoken  of  as  a  normal  condition.  It  is  also  called  the  physio- 
logical leiicocytosis  of  ilie  new-horn. 

TA'Jle  Xo.  OS. — TuhJf  Shoiriiu;  the  yaridthins  in  the  Xuntbcr  of  White  Blood 

CoriiUHfles  Found  hi/   Various  Writer.^. 

Rieder   15,500  10  minutes  after  birth 

Rietler   16.500  8  hours  after  birth 

Rieder  8.700  Third  day 

Rieder   3  cases,  13,600  Fourth  day 

Rieder    2  cases,  10.500  Fifth  day 

Rieder    3  cases,  12.200  Fifth  day 

Oransky    16.980  Immediately  after  birth 

Oransky   20,!)80  20  hours  after  birth 

Oransky    31,680  44  hours  after  birth 

Cadet    19.480  Immediately  after  birlh 

OrieflTcr  18.000  24     hours  after  birth 

Elder  &  Hutchinson,  average  12  ca.ses.  17.884  Immediately  after  birth 

After  the  second  year  the  number  gra(hially  declines  to  that  found  in 
adult  blood.  Gundobin  observed  an  increase  of  2000  to  4000  leucocytes 
after  feeding.  The  most  striking  peculiarity  in  the  differential  count  is 
the  increase  in  the  number  of  lympliocytes  and  the  more  or  less  propor- 
tionate decrease  in  the  polymorphonuclear  cells. 


728  DISEASES    OF    THE    BLOOD. 

Gundobin  gives  the  following  figures:  Lymphocytes,  50  per  cent,  to 
66  per  cent.;  polymorphonuclear,  28  per  cent,  to  40  per  cent.  The  weight 
of  the  child  has  no  influence  on  the  total  number  of  leucocytes  or  on  the 
proportions  of  the  dilferent  forms. 

Patholog^ical  Conditions. — In  disease  the  first  change  noticed  will  be 
a  reduction  in  the  percentage  of  haemoglobin,  and  also  in  the  number  of 
erythrocytes.     There  are  smaller  forms  of  red  corpuscles  called  nucrocytes. 

Nucleated  Red  Corpuscles  {Erythrohlasts). — These  cells  have  been 
found  in  prinuiry  and  secondary  anemias  by  many  observers.  They  have 
also  been  found  very  abundant  in  syphilis,  rachitis,  tuberculosis,  pseudo- 
leukgemia,  and  osteomyelitis. 

Leucocytosis. — In  leucocytosis  an  increase  in  the  number  of  leucocytes 
is  found  in  the  blood  of  anaemic  children.  It  is  also  found  in  toxic  and 
inflammatory  conditions.  Myelocytes  are  more  frequently  found  in  the 
blood  of  children  than  in  adults.  Cabot  and  Engel  ascribe  a  bad  prog- 
nostic significance  in  pneumonias  and  diphtherias  to  their  presence. 

Infectious-  Diseases. — In  diphtheria,  scarlatina,  pneumonia,  and  ery- 
sipelas the  polymorphonuclear  cells  are  greatly  increased  (Weiss  and  Gun- 
dobin). Gundobin  found  an  increase  in  the  number  of  leucocytes  before  the 
eruption  in  scarlet  fever,  measles,  and  erysipelas.  In  typhoid  fever  the 
number  of  leucocytes  is  decreased;  there  may  be  also  a  decrease  in  the 
number  of  red  corpuscles  and  in  the  percentage  of  haemoglobin.  The  num- 
ber of  leucocytes  is  relatively  increased.  The  polymorphonuclear  cells  are 
decreased. 

Pneumonia. — Leucocytosis  is  usually  present  in  this  disease.  When  it 
is  absent  the  prognosis  is  grave. 

Syphilis. — In  hereditary  syphilis  an  anaemia  is  found  with  a  decrease 
of  the  red  corpuscles  and  great  degenerative  changes  (poikilocytosis).  In 
syphilis  we  find  microcytes  and  macrocytes  and  nucleated  erythrocytes. 
Myelocytes  are  also  found.    Eosinophiles  are  also  met  with  in  this  condition. 

Bronchitis. — A  slight  leucocytosis  with  especial  increase  of  the  lympho- 
cytes or  mononuclear  cells. 

Gastro-intestinal  Disease. — The  condition  of  the  blood  varies  accord- 
ing to  the  extent  of  the  process,  the  duration,  and  the  existence  or  non- 
existence of  diarrhoea  and  vomiting.  Profuse  diarrhoea  and  vomiting  may 
for  a  time  thicken  the  blood  by  loss  of  water.  Weiss  shows  an  increase  of 
the  leucocytes  and  transitional  leucocytes. 

Rachitis. — There  is  usually  a  reduction  in  the  number  of  red  corpuscles, 
a  decrease  in  the  percentage  of  haemoglobin,  and  an  accompanying  leuco- 
cytosis according  to  von  Jaksch. 

Shin  Diseases. — There  is  an  increase  in  the  number  of  eosinophiles. 
The  cause  of  the  same  is  unknown. 

Nervous  Diseases. — In  the  functional  disorders  of  childhood  the  blood 


THE    BLOOD. 


729 


findings  are  those  of  a  moderate  ananiiia.  Burr  has  found  that  the  blood 
in  chorea  is  not  as  a  rule  anaemic.  In  my  own  examinations  (Fischer)  the 
opposite  result  has  been  found,  and  I  believe  that  in  prolonged  chorea  a 
distinct  leucocytosis  can  be  found. 

The  following  table,  prepared  by  Casper  Sharpless,  will  assist  in  the 
differentiation  of  the  blood : — 


Table  No.  99. 


l>isease. 

Leucocytosis. 

Lymphocytes. 

Neutrophiles. 

Red  Cells. 

Haemoglobin. 

Typhoid  Fever 

Absent 

Relatively 
increased 

Decreased 

Decreased 

Proportionately 
decreased 

Typhoid  with 
complications 

Present 

Increased 

Decreased 

Proportionately 
decreased 

Scarlet  fever    . 

Present 

Decreased 

Increased 

Decreased 

Proportionately 
decreased 

Measles.   . 

Absent 

No  change 

No  change 

Small  pox    .    . 

Marked  on 
third  day 

Increased 

Much  de- 
creased 

Proportionately 
decreased 

Erysipelas    .    . 

^larked 

Increased 

Decreased 

Proportionately 
decreased 

Diphtheria  .    . 

ISIarked 

Rarely 
increased 

Increased 

Slight  de- 
crease 

Proportionately 
decreased 

Influenza.    .    . 

No  change 

No  change 

No  change 

Typhus  fever 

No  change 

No  change 

No  change 

Follicular 
tonsillitis 

Moderate 

No  change 

Acute  rheu- 
matism . 

Moderate 

Increased 

Markedly 
decreased 

Markedly 
decreased 

Septicaemia . 

Marked 

Increased 

^larkedly 
decreased 

Proportionately 
decreased 

Abscess.    .    .    . 

Marked 

Increased 

Decreased 

Proportionately 
decreased 

Meningitis  . 

Marked 

Increased 

Slightly 
decreased 

Proportionately 
decreased 

Peritonitis 

Marked 

Increased 

Slightly 
decreased 

Proportionately 
decreased 

Pericarditis .    . 

Marked 

Increased 

Slightly 
decreiised 

Proportionately 
decreased 

Pleurisy  .    . 

Marked 

Increased 

Slightly 
decreased 

Proportionately 
decreased 

Malaria    .    . 

Absent 

Relatively 
increased 

Decreased 

Decreased 

Proportionately 
decreased 

Pneumonia  '    . 
Appendicitis 

Marked 
Marked 

Decreased 

Increased 

Decreased 

Proportionately 
decreased 

'  In  pneumonia  there  is  a  deciease  of  the  eosiiiojihiles  and  in  scarlet  fever  an  increase. 


730  DISEASES  OF  THE  BLOOD. 

Blood  Reaction  of  Pus. — The  glycogenic  reaction  of  tlic  l)lood  Inis  fre- 
quently been  described  in  literature.  The  first  complete  paper  on  this 
subject  was  published  by  Dr.  'SI.  Goldberger  and  Dr.  Siegfried  Weiss.^  This 
diagnostic  aid  is  of  value  when  a  questionable  diagnosis  exists. 

Through  the  courtesy  of  Dr.  Kunepfelnuicher,  physician  in  charge  of 
the  C'arolinen  Children's  Hospital,  in  Vienna,  I  saw  the  value  of  this  re- 
action. In  dilTerentiating  abdominal  symptoms  pointing  to  a  typhoid  fever 
or  a  supi)urative  appendicitis,  we  have  an  important  diagnostic  guide  in 
using  this  blood  reaction. 

EORMLLA  FOR    STAINING. 

IJ    Iddin    siiMim TVi!    grains 

Kill,  iodati 22  grains 

Aqiise  destil 1  ounce,   1   sciuple. 

iluc.  acacise.  ad.  consist,  syruposam. 

The  reaction  is  based  on  the  following:— 

1.  The  polynuclear  neutrophile  leucocytes  contain  very  many  irregular 
granules  of  glycogen.  These  have  a  brownish  color,  sometimes  a  reddish- 
brown  color. 

2.  ^fononuclear  leucocytes  usually  contain  large  granules  of  glycogen. 
Besides  the  above,  yellowish-brown  stained  e.xtra  cellular  masses  showing] 
the  glycogenic  reaction  are  also  found. - 

Meiliod  of  Tal-ing  a  Blood  Smear. — When  fever  exists  and  the  diagnosis 
is  obscure,  the  blood  should  be  examined.  A  drop  of  blood  can  be  withdrawn 
from  the  tip  of  the  finger  or  the  lobe  of  the  ear.  All  rules  of  asepsis  should 
be  strictly  api)lied.  The  needle  can  be  passed  through  an  alcohol  flame  or 
a  Bunsen  burner,  the  finger  or  ear  (piickly  pricked,  and  the  drop  of  blood 
thinly  smeared  over  the  cover  glass. 

Differential  Lcucocyie  Count. — When  the  polynuclear  percentage  is  70 
to  80,  and  there  is  a  marked  leucocytosis,  we  should  suspect  pus.  This 
l)lood  examination  must  be  used  to  support  the  other  symptoms  indicating 
an  empyema,  an  appendicitis  or  a  mastoid,  in  fact  any  suppurative  condition. 

Antibacterial  Action  of  the  Blood.- — According  to  Halliburton^  "the 
power  oF  the  l)lood  to  destroy  bacteria  was  fii'st  discovered  when  an  efl:'ort 
was  inade  to  grow  various  kinds  of  bacteria  in  it;  the  blood  was  believed 
to  be  a  suital)le  soil  for  tiiis  pur[)ose,  but  it  was  found  to  have  the  opposite 
effect  in  many  instances.  The  chemical  characters  of  the  substances  which 
kill  the  bacteria  are  not  fully  known.  Evidence  appears  to  favor  the  leuco- 
cytes as  the  origin  of  this  bactericidal  substance.  These  substances  are 
called  alexins,  but  the  more  usual  name  now  applied  to  them  is  that  of 

"■Wiener  Kliniscfie  Wochensclirift.  Mo.  25,  1897. 

^  An  interesting  contribution  on  tliis  subject  is  found  in  the  Transactions  of  the 
Section  on  Pediatrics  of  the  American  IMedical  Association,  .Tune,  1900,  by  Dr. 
Siegfried  Weiss. 

'Paper  read  before  tlie  British  As.sociation  for  the  Advancement  of  Science, 


PLATE   XX 

louopiiiLiA.     Pus  Reaction  of  Blood. 


Coverglass  Specimen  of  Blood  in  a  Case  of  Suppurative  Appendicitis. 
a,  Polj'niiclear  leucocj^tes;  h,  polynuclear  leucocytes  containing  manj-  irreg- 
ular granules  of  glycogen;  c,  extra-cellular  iodine-stained  masses,  giving  the 
reaction  of  glvcogen. 


a.  Pus  corpuscli's  witliout  iodine  reaction;   b,  pus  corpuscles,  iodine  reaction. 

(Original.) 


THE    BLOOD.  731 

bacteriolysins.  The  bactericidal  power  of  the  blood  is  closely  related  to  its 
alkalinity.  Increase  of  alkalinity  means  increase  of  bactericidal  power. 
xVlkalinity  is  probably  beneficial,  because  it  favors  those  oxidative  processes 
in  the  cells  of  the  body  which  are  so  essential  for  the  maintenance  of  healthy 
life.  Xormal  blood  jjossesses  a  certain  amount  of  substances  which  are 
inimical  to  the  life  of  bacteria.  When  a  person  gets  run  down  there  is  a 
diminution  in  the  bactericidal  power  of  his  blood.  However,  a  perfectly 
healthy  person  has  not  an  unlimited  supply  of  bacteriolysin,  and  if  the  bac- 
teria are  sufficiently  numerous  he  will  fall  a  victim  to  the  disease  which 
they  produce.  In  the  struggle  he  will  form  more  and  more  bacteriolysin, 
and  if  he  gets  well  it  means  that  the  bacteria  are  vanquished,  and  his  blood 
remains  rich  in  the  particular  bacteriolysin  he  has  produced,  and  so  will 
render  him  immune  to  further  attacks  from  that  particular  species  of  bac- 
terium. Every  bacterium  seems  to  cause  the  development  of  a  specific 
bacteriolysin.  Immunity  can  more  conveniently  be  produced  gradually  in 
animals,  and  this  applies,  not  only  to  the  bacteria,  but  also  to  the  toxins 
they  form.*' 

The  Blood  in  Fever. — There  is  a  decided  reduction  in  the  number  of 
red  cells  during  fever.  Whether  the  fever  destroys  the  red  cells  or  causes 
them  to  be  unequally  distributed  in  the  body  is  the  question.  Maragliano 
demonstrated  a  contraction  of  arterioles  during  the  height  of  a  febrile 
])rocess,  followed  Ijy  dilatation  during  defervescence.  He  was  able  to  verify 
these  results  by  noting  the  effect  of  antipyretics  (Ewing). 

Salkowski  demonstrated  an  excess  of  potassium  in  the  blood  during 
fever,  thus  favoring  the  view  that  the  red  cells  are  destroyed.  Senator, 
A'on  Jaksch,  and  others  have  shown  tliat  feln-ile  processes  are  regularly 
marked  by  diminished  alkalescence  of  the  blood.  When  diphtlieria  anti- 
toxin is  injected  the  alkalinity  of  the  blood  is  increased  for  about  tAventy- 
four  hours. 

The  progressive  loss  of  nlhumin  is  probably  associated  with  every  fever, 
but  occurs  in  a  marked  degree  when  the  fever  is  of  an  infectious  origin. 
])iininisli(Ml  resistance  of  the  rod  cells  occurs  in  the  majority  of  fevers  and 
depends  on  a  variety  of  factors,  ^'ariations  in  alkalinity  are  frequent  and 
considerable  in  fever,  but  are  not  i)roportional  to  either  the  toxicity  or  to 
the  height  of  the  tcnqjcrature  (according  to  Ewing). 

The  question  is,  why  do  almost  all  micro-organisms  which  are  harmful 
to  the  body  raise  its  temperature,  and  the  suggestion  has  been  made  that  the 
rise  of  temperature  is  a  defensive  mechanism,  or,  in  other  words,  pyrexia 
is  like  phagocytosis  or  chemiotaxis,  in  some  way  harmful  to  the  fever- 
producing  micro-organisms  or  their  toxins.  It  does  not  follow  from 
this  view  that  the  higher  the  temperature  of  the  body  the  better  the 
prognosis,  for  the  higher  temperature  might  be  taken  to  indicate  that  the 
dose  of  infection  was  very  severe,  and  that,  therefore,  the  body  did  all  it 


732  DISEASES    OF    THE    BLOOD. 

could  to  resist  the  invasion;  nor,  on  the  other  hand,  would  it  follow  that 
if  the  temperature  did  not  rise  much,  the  dose  of  infection  was  slight,  for 
it  might  he  that  the  body  was  feeble  and  had  but  little  power  of  raising 
its  temperature,  and  therefore  defending  itself. 

Some  years  ago  much  was  expected  from  the  antipyretic  drugs — anti- 
pyrin,  acetanilid,  and  phenacetin;  and  if  it  could  have  been  shown  that 
they  distinctly  improved  the  condition  of  the  fevered  patient  it  would  have 
been  a  strong  argument  against  the  view  that  pyrexia  is  a  defensive  mech- 
anism. 

When  fever  arises  and  a  distinct  diagnosis  cannot  be  made,  the  child 
should  be  put  on  the  expectant  plan  of  treatment.  This  will  consist  in 
cleansing  the  gastro-intestinal  tract,  regulating  the  diet,  and  noting  symp- 
toms as  they  arise.  This  is  especially  indicated  when  we  believe  the  case 
to  be,  in  the  period  of  incubation,  of  an  infectious  disease.  At  such  times 
the  following  recipe  is  a  good  antipyretic  and  will  not  depress  the  heart: — 

IJ  Sweet  spirits  of  niter 1  V2  fluidrachms 

Citrate  of  potassium 30  grains 

Syrup  of  lemon   4  fluidrachms 

Aquae q.  s.  ad     2  fluid  ounces 

A  teaspoonful  every  three  hours,  for  child  1  year  old. 

It  is  generally  helieved,  and  in  all  probability  correctly,  that  many 
cases  of  typhoid  fever  are  benefited  by  cold  sponging  or  by  a  cool  bath. 
Many  have  hastily  concluded  that  the  bath  does  good  because  it  lowers  the 
temperature.  But  this  is  probably  incorrect.  In  the  first  place  we  must 
remember  that  the  cold  sponging  or  bath  does  more  than  lower  the  tem- 
perature; it  diminishes  the  delirium,  the  tremor,  and  the  prostration.  In 
any  of  these  ways  it  would  do  good.  But,  further,  Eoque  and  Weil  claim 
to  have  shown  that  "in  typhoid  fever  left  to  itself  the  toxic  products  manu- 
factured by  the  bacillus  and  organism  are  eliminated  in  part  during  the 
illness.  The  urotoxic  coefficient  is  double  the  normal,  but  this  elimination 
is  incomplete  and  is  only  completed  during  convalescence,  for  the  hyper- 
toxicity  continues  for  four  or  five  weeks  after  the  cessation  of  the  fever. 
In  typhoid  treated  by  cold  baths  the  elimination  of  toxic  products  is  enor- 
mous during  the  illness.  The  urotoxic  coefficient  is  five  or  six  times  the 
normal.  The  hypertoxicity  diminishes  as  the  general  symptoms  mend  and 
as  the  temperature  falls,  so  that  when  the  period  of  pyrexia  and  convales- 
cence sets  in  the  elimination  of  toxins  has  ceased."  So  we  learn  that  it  is 
by  no  means  certain  that  in  typhoid  fevor  the  benefit  of  cold  baths  is  due 
to  their  antipyretic  influence  alone,  but  also  to  the  elimination  of  toxins. 
We  see  that  clinical  medicine  affords  no  evidence  that  antipyretics  are  useful 
in  fever. 


CHAPTEE  II. 

DISEASES  OF  THE  BLOOD. 

Anemia. 

A  DEFICIENCY  ill  the  number  of  red  blood-cells  or  of  the  hgemoglobin 
is  known  as  anieniia.  As  a  rule  there  are  two  distinct  forms :  first,  con- 
genital;  second,  acquired. 

Congenital  Form. — The  foetus  in  utero  is  frequently  ana?mic  owing  to 
the  inherited  disease  of  its  mother.  Such  diseases  are  blood  disorders  like 
syphilis,  or  where  a  general  devitalization  occurs,  as  seen  in  tuberculosis. 
If  the  mother  while  pregnant  passes  through  a  severe  form  of  diphtheria, 
lyphoid  fever,  or  any  other  infectious  disease,  it  may  result  in  angeraia  of 
her  offspring. 

Malarial  infection  of  the  mother  may  also  result  in  an  anaemia  of  the 
baby.  A  severe  hemorrhage  due  to  an  operation  on  the  mother  during  the 
last  period  of  her  pregnancy  may  cause  an  anaemia  of  the  baby. 

Acquired  Form. — This  form  is  due  to  either  an  infection  of  the  baby 
or  to  toxic  conditions  acquired  after  birth  and  independent  of  the  mother. 
Most  cases  of  acquired  anaemia  seen  by  me  are  the  direct  result  of  mal- 
nutrition. I  have  referred  in  detail  to  this  condition  in  the  chapter  on 
"Scurvy"  and  "Rachitis." 

Splenic  Anemia. 

"It  is  evident  that  some  of  the  cases  now  classified  as  pseud o-leukaemic 
anaemia  belong  to  the  group  of  the  simple,  severe,  chronic  anemia  of  young 
children — splenic  anemia.  Others,  possibly,  should  be  classed  as  leukaemia, 
but  cases  observed  at  Heubner's  clinic  indicate  that  although  the  blood 
presents  the  leukemia  formula,  the  affection  may  terminate  in  recovery. 
Alterations  in  the  red  corpuscles,  especially  the  appearance  of  megaloblasts, 
should  be  considered  pathologic  in  young  children.  The  total  number  of 
leucocytes  and  the  proportion  of  lymphocytes  in  this  splenic  anemia  are 
normally  larger  than  usual.  A  polynuclear  leucocytosis  may  be  transient. 
The  severe  forms  of  anemia  in  children  are  invariably  accompanied  by  an 
enlargement  of  the  spleen,  but  it  may  be  enlarged  also  in  mild  anemia, 
and  also  in  its  absence.  The  26  cases  described  by  Geissler  and  Japha  dem- 
onstrate the  existence  of  this  disease  of  the  blood  in  young  children,  espe- 
cially in  those  with  rachitis.  It  ranges  from  a  slight  decrease  in  the 
hemoglobin  and  the  number  of  the  reds  to  the  appearance  of  megaloblasts." 

(733) 


734  DISEASES    OF    THE    BLOOD. 

Secondaky  Anaemia. 

Causes. — Toxic  inllucnees  fivciuciitly  destroy  the  blood  corpuscles  and 
also  the  lueinoglobiu,  hence  anainiia  results.  \\'heu  lutMuorrhage  takes  place 
then  ancvniia  frequently  follows.  Malaria  and  whooping-cough  seem  to 
aflFect  chihlri'n  more  than  adults.  Other  diseases,  such  as  rheumatism  and 
endocarditis,  in  fact,  most  of  the  acute  infectious  diseases,  cause  an.T^mia. 
Improper  hygiene,  and  more  frequently  improper  food,  should  not  be  over- 
looked as  causative  factors. 

Symptoms. — A  pale  white  skin  and  waxy  appearance  of  the  nails  is 
the  usual  clinical  ])icture.  Children  do  not  appear  bright.  They  take  no 
interest  in  their  surroundings,  and  do  not  wish  to  i)lay.  Loss  of  appetite 
and  tendency  to  constipation  frequently  exist. 

Diagnosis. — This  is  usually  determined  by  the  condition  of  the  blood. 

Prognosis. — The  origin  of  the  anamiia  should  be  the  guide  in  deter- 
mining the  outcome  of  this  condition.  Great  care  should  be  used  in  ven- 
turing an  opinion,  unless  we  are  sure  of  the  origin  and  can  remove  the  cause 
of  same. 

Treatment. — Fresh  air,  food  (chiefly  proteids),  and  restoratives,  such 
as  codliver-oil,  lipanin,  inm.  Fowler's  solution,  and  malt  preparations,  are 
indicated.     Wine  or  champagne  is  sometimes  valuable. 

Pernicious  Anemia. 

This  rare  condition  is  sometimes  seen  in  children. 

Etiology. —  It  may  follow  simple  anivmia  so  that  it  would  appear  as 
the  result  of  a  continuation  of  malnutrition.  Many  theories  arc  offered. 
Tape-worm,  syphilis,  and  rachitis  are  believed  to  be  the  factors  causing  this 
condition. 

Pathology. — Hunter  first  reported  the  presence  of  a  deposit  of  iron  in 
the  hepatic  cells.  There  is  also  an  ampmia  of  the  internal  organs.  Some- 
times capillary  hannorrhages  are  seen  in  the  various  organs.  Fatty  degen- 
eration is  also  described  as  a  frequent  pathological  finding. 

General  Symptoms.- — These  are  the  same  as  previously  described  in  the 
article  on  ana-niia,  although  all  symptoms  are  of  a  more  severe  ty])e.  Epi- 
staxis,  in  addition  to  local  purpuric  spots,  denotes  the  tendency  to  haemor- 
rhages. An  interference  of  the  return  circulation  to  the  heart  is  manifested 
by  oedema  of  the  feet  and  ankles.  The  urine  contains  neither  albumin  nor 
casts. 

Special  Symptoms.— The  blood  will  furnish  the  real  means  of  diag- 
nosis. The  hanioglobjn  may  sometimes  be  as  low  as  20  to  30  per  cent. 
The  erythrocytes  are  reduced  in  number;  2,000,000  is  a  fair  average  red 
blood  count  in  this  condition,  although  Lenhartz^  refers  to  a  reduction  of 


^  Lenhartz — "Clinical  Microscopy,"  page  l.'ifi.      F.  A.  Davis  Co.,  1904. 


PLATE  XXI 


A. — Progressive  Perxiciois  Anaemia.  The  case  ended  fatally  in  six 
weeks;  cause  unknown;  possibly  in  connection  with  typhoid  fever.  Ehrlich's 
triiicid  stain.     Zeiss  ocular   1,  oil   immersion   Vi2-     «•   normal   erythrocytes; 

b.  nicfialocytes;    c,    miciocytes;    d,    marked    poikilocytosis;    e,    megaloblast; 
/■,  polynuclear  neutrophilic  leucocyte.      {Lenhartz-Brooks. ) 

Ji. — LiEXAL  (Splenic)  IjEUK.emia.  o,  normal  erythrocyte;  6.  nucleated 
erj'throcyte,  nucleus  eccentrically  situated;  r,  polynuclear  neutrophilic  leuco- 
cytes; d,  eosinophilic  (myelo)  cell.  The  eosinophilic  cell  at  the  top  has 
been  ruptured  and  the  fi^ranula  dispersed.  Two  small  greenish-blue  nuclei, 
perhaps  small  lymphocytes.      (Lenhartz-Brooks.) 

r. — LiENAL  (Splenic)  Leukemia.  ff/,  megaloblast:  n.  norma!  erythro- 
cyte; cr2,  megaloblast,  with  anremic  degeneration:    h.  |)olynuclear  leucocytes; 

c,  "marrow  cells"   (myelocytes);   d.  large  lymphocyte.      (Lenhartz-Brooks.) 

/>. — Ari'TE  Leik.kmta.  This  picture  is  made  from  two  ditrerent,  rajiidly 
fatal,  clinically  similar  cases.  The  upper  portion  is  stained  with  Khrlich's 
stain  with  eosin-hematoxylin;  the  lower  jjortion  is  stained  with  the  Plehn- 
Chenzinsky's  stain.      (Lenhartz-Brooks.) 


LEUKEMIA.  735 

erythrocytes  as  Ioav  as  -100,000   to   800/JOO.     There  is  also  an  enormous 
j)oikiloc3'tosis. 

In  this  disease  there  is  a  greater  reduction  in  the  number  of  red  blood 
cells  (oligocythaBmia)   than  in  any  other  disease. 

LeUK.T^MIA    (LEFKOCYTn.T^MIxV)  . 

In  tins  condition  we  have  a  reduction  of  the  red  corpuscles  and  a  cor- 
responding increase  in  the  white  l)lood  cells. 

Cellular  forms  called  lymphocytes  not  otherwise  found  in  health  are 
present  in  the  blood.  Yirchow  calls  this  condition  "wliite  blood."  Ehrlich 
calls  it  a  leucocytosis  of  a  chronic  type. 

Etiology. — This  is  unknown.  Some  authors,  Eoux  and  Lowit,  describe 
asporozoa  in  tl:e  blood  as  well  as  in  the  leucocytes  and  in  the  spleen.  Other 
writers  believe  that  there  is  a  predisposition  in  syphilitic  and  rachitic  chil- 
dren. Unsanitary  surroundings  and  injury  to  the  spleen  are  decided  etio- 
logical factors. 

The  following  classification  is  given  by  Ehrlich: — 

(a)  Lymphatic  forms. 

(b)  Myelogenous  and  splenic  forms. 

Lymphatic  Form. — When  the  colorless  corpuscles  are  as  large  as  a 
normal  erythrocyte  then  an  involvement  of  the  glandular  S3'stem  can  be 
diagnosticated. 

Myelogenous  and  Splenic  Forms. — If  large  cells  appear  then  bone- 
marrow  and  the  spleen  evidently  participate.  When  large  jnononucleated 
leucocytes  are  found  then  the  bone-marrow  is  probably  involved.  If,  in  the 
field  of  the  microscope,  three  to  five  or  more  cells  filled  with  strongly  re- 
fractive spheroid  granules  are  found,  the  splenic  involvement  should  be 
suspected. 

Pathology. — The  lesions  are  confined  to  the  bone-marrow,  lymphatic 
glands,  and  spleen.  The  spleen  is  enormously  enlarged,  sometimes  filling 
half  of  the  abdominal  cavity.  Sometimes  it  is  soft,  and  at  other  times  very 
hard  on  palpation.  It  has  a  dark  red  color.  In  the  lyuiphatic  form  any 
or  all  of  the  external  glands  of  the  body  may  l)e  affected  ;  tlms  the  cervical, 
nuixiilary,  bronchial,  mesenteric,  or  inguinal  glands  may  be  involved. 
There  is  a  simple  hyperplasia  found  in  the  glands.  The  liver  is  usually 
enlarged  from  an  infiltration  with  lymphoid  tissue.  The  lymphoid  tissue 
in  the  tonsils  and  the  thymus  gland  have  the  same  changes.  Ha3morrhages 
are  not  infrequent. 

Symptoms  and  Diagnosis. — The  disease  is  usually  ushered  in  by  a  severe 
luvMiiorrhage.  after  which  profound  anaemia  and  a  general  weakness  are  noted. 
The  spleen  is  always  enlarged  and  the  lymphatic  glands  are  palpable.  The 
glands  are  movable,  but  never  tender  on  palpation.  The  liver  is  usually 
enlarged.    In  the  beginning  there  is  little  or  no  fever,  although  later  in  the 


736  DISEASES    OF    THE    BLOOD. 

disease  the  temperature  may  rise  as  high  as  103°  F.  Sometimes  from  in- 
volvement of  the  liver  there  will  be  dropsy  of  the  feet  or  a  general  anasarca. 
Haemorrhages  from  the  nose,  mouth,  stomach,  and  bowels  frequently  com- 
plicate this  condition.     From  the  loss  of  blood  fainting  spells  may  occur. 

The  Blood. — The  characteristic  feature  is  an  increase  in  the  number 
of  leucocytes.  The  normal  ratio  between  the  red  and  white  corpuscles  varies 
l)etween  1  to  500  and  1  to  1000.  In  leukaemia  the  ratio  is  so  altered  that 
we  may  have  one  colorless  corpuscle  to  twenty,  or  even  to  five,  red  corpus- 
cles.    Some  authors  report  a  ratio  of  one  red  to  two  white  corpuscles. 

The  eosinophiles  are  frequently  increased  many  times  their  normal 
number.  A  characteristic  feature  is  the  presence  of  large  and  small  mono- 
nuclear lymphocytes.  Ehrlich  describes  a  large  mononuclear  nutrophilic 
staining  cell  which  normally  exists  in  the  bone-marrow,  and  is  found  in  the 
myelogonous  form  of  leukaemia.     It  is  called  the  myelocyte. 

Treatment. — The  nutrition  of  the  child  must  be  carefully  considered. 
Albumin  and  the  cereals  should  form  the  main  portion  of  the  food.  All 
vegetables  should  be  ordered.  If  the  child  can  be  taken  out  of  doors,  then 
the  same  should  be  insisted  upon.  Strict  attention  to  hygienic  details  will 
greatly  assist  in  modifying  this  condition. 

Medication. — Iron,  arsenic,  in  the  form  of  Fowler's  solution,  cod- 
liver-oil,  and  malt  extracts  should  be  given.  If  there  is  anorexia  then 
strychnia  or  nux  vomica  should  be  given. 

PSEUDO-LEUK^MIC    An.EMIA    OF    INFANCY    (An.IIMIA    INFANTUM 

Pseudo-Leuk^mica)  . 

Von  Jaksch  was  the  first  to  describe  this  disease  in  1(S89.  It  is  an 
infantile  ana;mia  characterized  by  the  following  conditions: — 

1.  I'here  is  a  marked  enlargement  of  the  spleen. 

2.  A  slight  enlargement  of  the  liver  and  the  lymph  nodes. 

3.  A  marked  reduction  in  the  number  of  red  corpuscles. 

It  is  usually  a  secondary  anaemia  rather  than  a  primary  disease. 

Etiology. — The  disease  is  usually  found  in  infants  and  children  be- 
tween G  months  and  4  years  of  age. 

Monti  and  Berggrun  collected  16  cases  in  1892.  Kickets,  congenital 
syphilis,  chronic  intestinal  catarrh,  and  tuberculosis  were  found  in  cases 
collected  by  Fischl. 

Pathological  Anatomy. — The  spleen  is  enlarged  and  rather  firm. 
Histologically,  the  changes  are  those  of  simjde  hyperplasia  of  all  elements, 
while  the  sinuses  contain  no  excessive  number  of  leucocytes.  Baginsky 
found  many  eosinophile  cells  in  the  spleen.  The  changes  in  the  viscera  are 
described  by  Von  Jaksch,  Eppinger,  Luzct,  Baginsky,  Audeoiid,  and 
Rotch. 


CHLOROSIS.  737 

The  marrow,  according  to  Luzet,  is  diffusely  reddened  and  moist  and 
shows  evidence  of  excessive  multiplication  of  the  red  cells. 

The  Blood. — Leucocytosis  is  an  important  symptom.  The  white  blood 
cells  number  between  20,000  and  r)().000.  Other  cases  (Baginsky)  between 
40,000  and  123,000. 

According  to  Monti  the  proportion  of  white  cells  to  the  red  may  be 
as  1  to  100  or  1  to  15. 

Symptoms. — After  a  prolonged  gastro-intestinal  disease  an  infant  will 
appear  very  anaemic.  Fever  is  not  usually  present.  When  fever  is  pres- 
ent the  cause  of  the  same  will  usually  be  found  other  than  in  the  spleen. 
Icterus  is  sometimes  present. 

There  is  a  decided  loss  of  appetite  and  the  bowels  move  sluggishly. 
The  skin  has  a  yellowish  color  and  is  intensely  anaemic.  The  abdomen 
appears  distended.  The  liver  is  slightly  enlarged.  The  lymph  glands  are 
palpable.  The  spleen  is  very  much  enlarged  and  occupies  the  left  hypo- 
ehondrium,,  reaching  at  times  to  the  crest  of  the  ilium. 

Prognosis. — The  prognosis  is  poor,  although  recovery  does  take  place 
in  some  instances.  A  case  of  this  kind  seen  by  me  has  shown  marked  im- 
provement under  anti-rachitic  and  restorative  treatment. 

Treatment. — Tonic  doses  of  iron,  quinine,  and  strychnine  served  me 
well.  Codliver-oil  and  the  glycerophosphites  of  lime  and  soda  are  indi- 
cated. Phosphorus  has  been  recommended  by  some.  The  bowels  must  be 
thoroughly  cleansed,  and  the  general  peristalsis  stimulated.  ISTux  vomica, 
in  1  minim  doses  three  times  a  day,  when  anorexia  and  gastric  atony  are 
present.  Fresh  air  and  general  hygienic  management,  in  addition  to  a 
supporting  diet,  will  do  more  toward  building  up  and  restoring  the  system 
than  all  medication  combined. 

Chlorosis. 

This  is  a  primary  anaemia  which  is  usually  found  in  girls  at  or  about 
the  period  of  menstruation.  In  our  climate  chlorosis  can  be  seen  between 
the  twelfth  and  twentieth  years  of  age.  Blondes  are  more  prone  to  tliis 
disease  than  brunettes. 

Etiology. — Sedentary  occupation  associated  with  lack  of  exercise,  or 
poor  hygienic  surroundings,  may  induce  this  condition.  N"ervous  girls 
susceptible  to  mental  influences,  such  as  fright  or  worry,  are  uiore  prone 
to  the  development  of  this  condition  than  robust,  healthy  girls.  Auto- 
intoxication is  certainly  a  factor,  as  T  ha\c  froqiiontly  seen  chlorosis  in 
girls  suffering  with  chronic  consti])ation. 

Pathology. — Distinct  pathological  lesions  cannot  be  attributed  to  this 
condition.  In  some  cases  ulcer  of  the  stomach  is  associated,  and  this  latter 
condition  nuiy  be  fatal. 


738  DISEASES    OF    THE    BLOOD. 

Symptoms. — The  syinptoins  are  those  described  in  the  chapter  on 
"anaemia.""  'ilie  appetite  is  poor  and  such  girls  invariably  crave  for  sour 
and  spiced  I'oods  to  stimulate  the  ajipetite.  Constipation  is  most  alway^ 
present.  Headache  and  other  ner\()us  syuiptoms  are  also  present.  Such 
girls  are  -very  emotional,  and  cry  and  laugh  very  easily.  They  are  very 
sensitive.  A  venous  murmur  can  usually  be  made  out  in  the  vessels  of 
the  neck-  There  is  a  blowing  systolic  murmur  which  can  be  heard  over 
the  heart  in  tlie  mitral  region  and  also  in  the  region  of  the  pulmonary 
artery.  A'enous  thrombosis  is  most  frequently  seen  in  the  femoral  veins, 
and  varicose  veins  are  sometimes  seen  over  the  thighs  and  ankles.  Men- 
struation is  irregular  and  the  flow  is  scanty  or  very  profuse  and  someti'nes 
painful.  There  is  a  decrease  in  the  percentage  of  hsemoglobin  and  also  a 
decrease  in  the  number  of  red  corpuscles.  The  number  of  red  cells  may 
be  reduced  to  4,000,000. 

The  spleen  may  be  slightly  enlarged,  but  on  this  symptom  no  reliance 
can  be  placed.  A  puffiness  of  the  face  or  oedema  of  the  ankles  due  to  a 
sluggish  return  circulation  is  occasionally  seen. 

The  skiu  is  of  a  greenish-yellow  color.  When  localized  areas  of  pain 
are  complained  of  in  the  region  of  the  stomach,  then  gastric  ulcer  should 
be  suspected.  In  such  cases  an  examination  of  the  gastric  contents  should 
be  made  with  the  aid  of  a  test-meal  (see  page  915,  Part  XII),  to  see  whether 
or  no  hyperacidity  is  present.  The  eyes  usually  have  a  pec\iliar  pearly 
sclerotic  appearance. 

Diagnosis. — Chlorosis  is  met  with  in  girls  only  at  or  about  the  period 
of  menstruation.  This  is  its  characteristic  diagnostic  feature.  Such  chil- 
dren, as  a  rule,  are  fat  and  look  well  nourished. 

Prognosis. — This  is  always  good,  although  the  disease  nuiy  last  sev- 
eral years.  If  chlorosis  is  a  forerunner  of  tuberculosis  or  gastric  ulcer, 
then  a  fatal  termination  may  occur.  The  outcome  of  a  case  depends  on 
heroic  restorative  treatment. 

Treatment. — Ifi/giciiic  'Treatment:  I\emove  the  child  from  its  imme- 
diate surroundings,  from  the  city  to  the  country.  If  chlorosis  occurs  in  a 
girl  living  at  a  boarding-school,  in  a  convent,  or  in  a  girl  working  in  a 
factory,  the  hygienic  conditions  demand  : — 

1.  To  sleep  in  an.  airy  room  with  the  windows  open  at  night. 

2.  Discontinue  working,  or  studying  if  at  school,  to  procure  mental 
rest. 

3.  Change  the  entire  mode  of  living,  so  that  there  is  neither  care  nor 
worry  for  the  chlorotic  girl. 

Exercise. — Gentle  exercise,  walking,  swimming,  the  lighter  exercises  of 
physical  cidture  followed  by  a  shower-bath  and  massage  are  valuable.  Fric- 
tion with  a  coarse  towel  after  the  daily  sponge  bath  is  useful  to  stimulate 
the  circulation.    Reading  or  sewmg  at  night  must  be  forbidden. 


CHLOROSIS.  739 

Nutrition. — To  stimulate  metabolism  nothing  equals  food.  Troteids 
iu  the  form  of  miik,  meat,  eggs,  cereals,  cream,  butter,  and  cheese  should 
be  liberally  gi\en.  All  fresh  fruits  may  be  allowed.  IJegularity  in  feeding 
must  be  demanded,  although  a  drink  of  milk,  buttermilk,  cocoa,  or  zoolak 
may  be  taken  between  meals. 

Medicinal  Treatment. — Soluble  preparations  of  iron,  such  as  ovoferrin 
and  neoferrum,  may  be  given  in  teaspoonful  doses  after  each  meal.  Arsenic 
in  the  form  of  Fowler's  solution  or  arsenious  acid  may  be  combined  with 
the  iron.  The  arseniated  ha^maboloids  have  been  tried  by  me  with  good 
result.  Maltine  with  or  without  hypophosphites  may  be  tried  three  times  a 
day.  Codliver-oil,  morrholine,  or  lipanin  may  be  tried  in  teaspoonful  doses 
three  times  a  day  given  after  meals.  The  sun  bath  or  the  electric  light 
bath  may  be  tried  in  conjunction  with  the  above-described  treatment. 


CHAPTEE  III. 

ACUTE  RHEUMATISM   (POLYARTHRITIS). 

Tins  disease  is  sometimes  known  as  rheumatic  fever,  also  as  inflam- 
matory rheumatism.  It  is  an  acute,  infectious,  but  non-contagious  disease. 
The  infection  is  characterized  by  an  inflammation  which  localizes  in  the 
joints,  and  travels  from  joint  to  joint,  evidently  through  the  circulation. 
The  most  frequent  complication  is  endocarditis. 

Etiology. — The  specific  factor  is  evidently  a  micro-organism.  A  great 
many  observers  have  studied  this  subject,  among  them,  Leyden,  Sahli, 
Achalme,  Kiva,  Triboubet,  Coyon,  Singer,  Jaccoud,  and  many  others.  A 
bacillus  described  as  an  anaerobic,  with  more  or  less  motility,  similar  to  the 
anthrax  bacillus,  has  been  described  by  Achalme.  This  bacillus,  when  in- 
jected into  animals,  has  reproduced  symptoms  resembling  rheumatism. 
Thus  this  observer  believes  he  has  found  the  specific  agent  causing  this 
disease. 

Other  causes  have  been  described  as  the  result  of  defective  assimila- 
tion, which  produces  lactic  acid  oi  combinations  of  it.  Another  theory 
is  the  so-called  nervous  theory,  in  which  the  nerve  centers  are  primarily 
affected  by  cold,  and  the  local  lesions  are  atrophic  in  character. 

This  nervous  disturbance  brings  about  hurtful  metabolism,  so  that  the 
nitrogenous  products,  instead  of  being  converted  into  urea,  are  transformed 
into  uric  acid  and  other  poisonous  products  which  cause  these  symptoms. 

Whether  or  not  heredity  bears  any  relationship  to  the  cause  of  this 
disease  may  be  considered  by  the  fact  that  in  two-thirds  of  the  cases,  dis- 
eases of  a  similar  type  can  be  traced  to  the  ancestors.  Gouty  parents 
will  usually  have  rheunuitic  children.  The  disease  is  very  common  in 
children,  and  has  also  been  observed  in  nurslings. 

Iiheumatism  occurs  more  often  in  the  spring  of  the  year.  When  the 
disease  has  commenced,  it  usually  lays  the  foundation  for  future  attacks; 
in  other  words,  one  attack  of  rheumatism  predisposes  to  future  attacks  of 
the  disease. 

The  tonsils  have  frequently  been  looked  u])on  as  the  seat  of  entrance 
of  this  disease;  thus  acute  tonsillitis  has  frequently  been  followed  by  acute 
articular  rheumatism.  In  the  same  manner  endocarditis  has  frequently 
followed  an  attack  of  tonsillitis.  It  is  therefore  safe  to  assume  that  tin' 
specific  entrance  of  an  infection  can  originate  in  a  diseased  tonsil. 

Packard  has  described  a  series  of  cases  of  endocardial  inflammation 
(740)  '. 


ACUTE    RHEUMATISM.  741 

following  tonsillitis.  He  regards  a  serous  intlanimation  as  due  to  the  germs 
or  other  toxins  entering  the  circulation  through  inflamed  tonsils. 

Bacteriology. — Triboulet  and  Coyon^  give  the  results  of  their  bac- 
teriologic  examinations  in  11  cases  of  acute  articular  rheumatism.  They 
discovered  in  all  these  cases  a  diplococcus  or  diplobacillus  which  they  state 
cannot  be  well  described  as  to  its  cultural  peculiarities,  as  its  growth  is  so 
irregular. 

The  organism  exhibits  great  plesiomorphism  and  resembles  most  closely 
in  character  the  diplococcus  pneumonia^,  but  differs  from  it  in  that  it  can 
be  kept  alive  for  a  considerable  length  of  time,  and  that  it  is  not  patho- 
genic for  mice.  The  organism  is  extremely  pathogenic  for  rabbits,  and 
the  authors  give  a  detailed  account  of  its  effects  on  a  rabbit.  The  animal 
died  twenty  days  after  intravenous  inoculation.  Death  was  due  to  heart 
failure  resulting  from  an  absolute  mitral  insufficiency.  During  life  there 
was  an  oscillatory  temperature.  The  autopsy  showed  fresh  pleuritis  and 
pericarditis,  and  an  acute  vegetative  endocarditis  with  tremendous  masse- 
of  vegetations  on  the  mitral  valve.  Tlie  vegetations  microscopically  showed 
numy  diplobacilli  similar  to  those  originally  inoculated,  and  cultures  from 
the  organs  also  showed  it.  Other  rabbits  inoculated  with  smaller  doses  from 
other  cases  showed  irregular  fever,  disturbances  of  the  heart,  and  pleurisy, 
but  did  not  die. 

Symptoms. — The  sym])tonis  are  entirely  different  from  those  met  with 
in  adults.  The  fever  is  not  so  high,  usually  between  100°  and  102°  F. 
The  swelling  of  the  joints  is  moderate,  and  there  is  not  the  redness  and 
inflammation  visible  to  the  eye  as  we  see  it  in  adults.  The  pains  are  not 
severe  in  all  cases,  and  there  are  less  joints  involved  as  a  rule  than  we 
tind  in  adults.  We  therefore  meet  with  a  great  many  cases  of  rheumatism 
that  walk  around  suffering  slight  pains.  Sometimes  the  lower  extremities 
arc  affected,  at  other  times  the  disease  is  limited  to  the  upper  extremities. 
A  child  may  walk  apparently  lame  or  an  infant  may  cry  when  put  on  its 
feet.  Jacobi  3'ears  ago  directed  the  attention  of  the  profession  to  the 
necessity  of  carefully  watching  every  case  of  so-called  "growing  pains." 
He  believed,  and  correctly  so,  that  the  majority  of  these  cases  were  in 
reality  rheumatism.  The  most  rrccjucnt  symptoms  are  vomiting,  fever,  gen- 
eral malaise,  anorexia,  in  addition  to  multiple  arthropathy. 

Rhenniatism  a  Sequela  to  Tonsillitifi. — ^That  rlieumatism  is  irequently 
a  sequel  to  tonsillitis  has  been  noted  by  many  observers.  Packard,  of  Phila- 
delphia, has  reported  a  series  of  cases  in  which  the  throat  was  first  affected 
and  later  heart  disease  was  distinctly  manifested.  Emil  Mayer,  of  Xew 
York  City,  has  also  reported  a  series  of  cases  in  whicli  the  tonsils  were  the 


Conijites  ReiiduM  de  la  Soc-ietc'  de  T^iologio,  February  4,  1898. 


742  DISEASES    OF    THE    BLOOD. 

portals  of  infection.  This  is  certainly  not  a  theory  when  we  study  the 
IH'imary  infection  and  follow  it  up  with  its  secondary  result. 

Sir  Willoughby  Wade^  says,  in  relationship  between  tonsillitis  and 
rheumatic  fever,  he  believes  that  tonsillitis  is  a  primary  infective  disease 
of  the  lacunge;  rheumatic  fever  a  secondary  disease  arising  from  the 
absorption  of  microbes  or  their  products  into  the  system.  Knowing  this 
to  be  a  factor,  it  would  only  seem  proper  to  treat  every  tonsillitis  as  vigor- 
ously as  possible. 

Acute  Contagious  Articular  Klieuuiatisiii. — G.  B.  Allari  reports  3 
cases  which  were  characterized  by  contagiousness  and  at  the  beginning  of 
the  disorder  with  angina  of  the  throat.  In  the  fourth  case  the  angina  re- 
appeared with  every  reappearance  of  exacerbation  of  the  articular  symptoms. 
Bacteriological  investigations  of  the  exudate  on  the  tonsils  showed  in  each 
case  a  streptodiplococcus  which  was  almost  identical  in  structure  and  be- 
havior with  that  found  by  Mayer  in  the  same  affection.  Animals  inoculated 
with  this  micro-organism  developed  lesions  in  the  joints. 

Subcutaneous  Tendinous  Nodules. — Barlow  and  Warner  described  this 
manifestation  of  rheumatism  in  1881  as  oval  semi-transparent  fibrous  bodies 
like  boiled  sago  grains.  They  are  most  frequently  met  with  at  the  back  of 
the  elbow,  over  the  malleoli,  and  at  the  margin  of  the  patella.  Occasionally 
on  the  cxtensior  tendons  of  the  hands,  fingers,  and  toes,  or  over  the  spinous 
processes  of  the  vertebra\  They  are  composed  of  fibrin,  cells,  and  fibrous 
tissue.  They  vary  in  size  from  a  pin-head  to  a  small  bean,  though  some- 
times beibg  as  large  as  an  almond.  They  may  remain  for  months,  although 
they  frequently  disappear  in  a  few  weeks.  Cheadle  states  that  they  can  be 
seen  if  the  skin  is  tightly  drawn.  Cheadle  has  also  shown  the  intimate  rela- 
tionship between  erythema  and  rheumatistn. 

Purpura. — This  is  frequently  met  with  in  the  course  of  rheunuitism. 
It  is  a  rash  of  a  deep  purplish  hue  and  is  most  probably  a  result  of  rheu- 
matism. 

Complications. — The  most  frequent  form  of  complication  is  endocar- 
ditis. Fully  75  per  cent,  of  my  cases  met  with  in  a  large  outdoor  practice 
showed  this  form  of  complication.  This  complication  has  frequently  l^een 
the  first  symptom  that  led  to  the  discovery  that  our  patient  had  rheuma- 
tism. 

Pericarditis  is  rarely  seen  in  children  under  7  years  of  age.  It  is 
usually  associated  with  endocarditis. 

Pleurisy,  peritonitis,  or  meningitis  may  complicate  rheumatism. 
Chorea  frequently  associates  itself  with  rheumatism,  so  that  a  great  many 
authors  believe  that  there  is  an  intimate  relationship  between  rheumatism 
and  chorea. 


I 


'  British  Medical  Journal,  1898. 


ACUTE    RHEUJVIATISM.  743 

Holt  states  that  in  a  series  of  cases  of  chorea  observed  b}'  him^  56 
per  cent,  gave  evidence  of  the  rheumatic  diathesis. 

Prognosis  and  Course. — The  course  of  rheumatism  depends  on  the 
treatment.  Pains  in  the  joints  should  never  be  regarded  as  a  trivia), 
matter.  How  frequently  do  we  see  a  child  suffering  with  what  the  mother 
calls  "growing  pains,"  and  a  few  weeks  or  months  later  we  note  shortness 
of  breath  due  to  heart  trouble,  usually  endocarditis.  It  is  better  to  put  a 
child  to  bed  than  to  run  risks  of  such  a  serious  complication.  The  prog- 
nosis depends  on  the  care  bestowed,  although  we  know  that  this  disease  has 
a  tendency  to  assume  a  chronic  course.  However,  a  case  with  proper  treat- 
ment should  recover  entirely.  The  inflammatory  stage  lasts  from  ten  days 
to  two  weeks.  Cases  of  inflammatory  rheumatism  complicating  scarlet 
fever  or  diphtheria  lasting  between  three  and  eight  weeks  have  been  seen 
by  me  during  my  hospital  service. 

Ehcumatism  in  children  assumes  the  course  of  a  general  infectious 
malady.  The  intensity  of  cardiac  complications  cannot  be  approximated 
by  the  intensity  or  mildness  of  articular  manifestations.  Many  authorities 
state  that  the  percentage  of  cardiac  complications  is  between  81  and  87 
per  cent. 

Lethal  termination  will  frecpiently  show  pericarditis,  hence  the  im- 
portant deduction  is  to  prevent  such  complications,  if  possible,  by  proper 
prophylactic  treatment. 

Treatment. — The  first  thing  to  do  is  to  put  the  child  in  bed.  The 
patient  should  be  kept  in  bed  imtil  every  particle  of  pain  and  fever  is  gone. 

1.  When  the  disease  is  localized  we  can  treat  the  same  and  try  to 
destroy  as  much  of  the  pathogenic  infection  as  possible. 

2.  The  important  point  would  be  to  restore  the  subnormal  condition  at 
the  time  of  the  invasion  of  these  infective  germs,  and  prevent  thereby  the 
absorption  of  the  toxins  generated  from  these  micro-organisms. 

3.  Watch  for  possible  complications.  While  it  is  true  that  we  can 
limit  by  local  treatment  the  spread  of  active  infective  processes,  on  the 
other  hand,  when  the  body  is  weakened  from  anaemia,  or  from  other  de- 
pressing influences,  this  infection  will  spread  in  spite  of  the  most  vigorous 
local  treatment. 

Rest  must  be  enjoined,  more  so  in  children  with  this  disease  than  in 
most  other  diseases.  We  must  aim  to  have  the  most  perfect  physiological 
repose.  In  tliis  way  we  liave  tlie  longest  iiit('i-\;il  between  th(!  systoles  and 
we  keep  down  the  l)lood  ])ressure. 

rropJiyhicllr  Treatment. — In  trying  to  prevent  rhoumatism  the  hy- 
giene of  the  skill  recinires  caret'iil  attention.  The  body  sliould  1)0  properly 
protected,  duo  allowance  being  made  for  sudden  changes  in  the  weather. 
Too  much  clothing  moans  overheating.  Perspiration  induced  thereby  in- 
vites this  disease  when  the  surface  is  suddenly  chilled.    Overheated  apart- 


744  DISEASES    OF    THE    BLOOD. 

iiieiits  render  children  peculiarly  susceptible  to  this  disease.  Proper  ven- 
tilation, without  incurring  any  draught,  is  urgently  demanded.  Cool  or 
tepid  bathing  or  sponging  has  a  very  good  effect  on  the  skin.  Unneces- 
sary and  useless  hardening  of  children,  by  exposing  them  to  cold  baths  in 
cold  rooms,  without  proper  protection,  will  certainly  invite  this  disease. 

Dietetic  Treatment. — Milk  and  milk  foods;  cereals  and  fruits,  espe- 
cially acid  fruits ;  broths  and  all  soups  made  from  meat  are  indicated.  For 
thirst,  buttermilk,  and  all  fermented  milks,  seltzer  and  milk,  alkaline  waters, 
lithia,  apollinaris,  white  rock,  lemonade,  and  orangeade. 

Medicinal  Treatment. — The  alkaline  treatment  known  as  Fuller's 
method  has  been  abandoned  many  years  ago.  The  first  thing  to  do  is  to 
cleanse  the  gastro-intestinal  tract.  A  wineglassful  or  more,  depending  on 
the  age  of  the  child,  of  citrate  of  magnesia,  repeated  every  two  hours,  until 
its  effect  is  produced.  Ehubarb  and  soda,  5  to  10-grain  doses,  or  calomel, 
is  valuable.  Salicylate  of  soda,  3  grains  every  three  hours,  for  a  child  3 
years  old.  Older  children  in  proportion.  This  treatment  should  be  con- 
tinued two  or  three  days,  if  the  drug  is  well  borne : — • 

IJ  Natr.    salicylat 1  drachm 

Elix.    lactopeptin 2  ounces 

M.     Sig. :      One  dracLni  every  three  lionrs  may  be  given. 

Salol  or  salophen,  in  doses  of  3  to  5  grains,  is  indicated.  Aspirin  is 
a  valuable  remedy  in  doses  of  3  to  10  grains  given  every  three  hours. 
Cotton  saturated  with  the  oil  of  wintergreen  applied  over  the  affected 
joints,  the  whole  covered  with  oil  silk,  is  recommended. 

Fever. — Fever  requires  the  same  treatment  in  this  disease  as  in  all 
others.     Cold  sponging  of  the  surface  will  do  good. 

Restorative  Treatment. — The  profound  anannia  caused  by  this  disease 
is  an  indication  for  early  restorative  treatment.  We  should  therefore  aid 
nutrition  by  giving  cream,  butter,  and,  if  tolerated,  codliver-oil,  with  or 
without  malt.  Iron  and  iodide  of  sodium  are  good  restoratives.  Fellows' 
syrup  of  the  hypopliosphites  may  l)e  tried.  The  application  of  leeches, 
blisters,  or  sinapisms  sometimes  does  good.  Ice-bags  a])plied  over  inflamed 
joints  will  reduce  swelling,  remove  heat,  and  have  a  very  soothing  effect. 

An  ice-hag  applied  over  the  heart  if  endocarditis  complicates  has  served 
me  quite  well  in  some  cases.  For  the  management  of  heart  complications, 
see  chapter  on  "Heart  Diseases." 

It  is  vital  to  stimulate  the  action  of  the  kidneys.  For  this  reason  I 
have  previously  mentioned  the  alkaline  mineral  v/aters.  If  a  diuretic  is 
indicated  none  is  better  than  ?>asham's  mixture.  See  formula  in  chapter 
on  "Scarlet  Fever,"  page  GG7. 

The  following  ointment  is  useful  applied  on  gauze  to  the  affected 
joint : — 


MUSCULAR    RHEUMATISM.  745 

IJ  Methyl  salicylate  1  part 

Vaseline 10  parts 

Mix. 

Apply  morning  and  evening. 

Warm  Bathing. — By  adding  irulphur  in  the  form  of  kalium  sulphuret, 
about  1  ounce  to  an  infant's  batli-tub  of  water,  and  bathing  the  affected 
joints  at  a  temperature  of  95°  to  100°  F.,  is  sometimes  very  grateful  and 
weJl  borne.  It  is  not  advisable  to  make  sudden  changes  in  the  local  treat- 
ment. If  ice-bags  have  been  used  and  are  well  borne,  they  should  be 
continued.  Sulphur  baths,  so  also  pine-needle  baths,  are  very  grateful  in 
the  evening,  and  sometimes  promote  slee]).  When  pains  are  very  severe, 
full  doses  of  codeine  or  chloralamid  may  be  given.  It  is  seldom  that  so 
much  truth  is  contained  in  a  single  sentence  as  in  the  following  from 
Cheadle:  "The  various  manifestations  of  rheumatism  massed  together  in 
the  case  of  adults  tend  to  become  isolated  in  the  case  of  children,  so  that 
the  whole  phenomena  are  distributed  over  years  instead  of  Aveeks  or  months, 
and  the  history  of  a  rheumatism  may  l)e  tlie  history  of  a  whole  childhood.'' 

Muscular  Eheumatis]\i  (Myalgia). 

This  painful  condition  is  rarely  seen  in  children.  It  is  characterized 
by  pain  when  the  muscles  affected  are  brought  into  play.  When  the  dis- 
ease affects  the  muscles  of  the  neck  it  is  called  acute  torticollis.  When  the 
intercostal  muscles  are  affected  it  is  called  pleurodynia.  When  the  lumbar 
muscles  are  affected  it  is  called  lumbago.  Peculiar  contractions  of  the 
muscles  frequently  follow  persistent  muscular  rheumatism  and  sometimes 
cause  permanent  deformity  (see  chapter  on  ^'Torticollis").  Infants  so 
affected  usually  cry  when  the  group  of  muscles  involved  are  moved.  There 
is  no  fever  present. 

R.  K,,  16  years  old,  was  attacked  with  a  severe  tonsillitis.  The  cervieal  glands 
were  enlarged  and  tender  on  palpation.  Creosote  inhalations  and  unguentum  Crede 
rubbe(l  into  the  glands  of  the  neek  relieved  this  condition.  Two  days  later  after 
going  out  into  the  street  she  had  violent  muscular  pains  involving  the  back,  groin, 
and  muscles  of  the  thigh.  It  was  a  distinct  lumbago  und  a  general  myalgia.  There 
wa.s  also  a  painful  sciatica.  With  the  aid  of  massage  and  the  internal  administra- 
tion of  5  grains  {0..3)  salophen  every  four  hours  these  pains  gradually  subsided. 
After  these  pains  left  there  were  pains  involving  the  intercostal  muscles,  so  that  wo 
had  a  lumbago  followed  by  pleurodynia.  Rest  in  bed,  warmth,  and  massage  relieved 
this  condition  permaiiently. 

Treatment. — Local  treatment  consisting  of  massage  aided  by  gentle 
faradic  oloctricitv  is  very  useful.  Warm,  moist  fomentations,  such  as  flax- 
geed  meal  poultices,  are  very  soothing  and  seem  to  do  good.  The  internal 
administration  of  salicylate  of  soda  has  not  seemed  to  benefit  my  cases. 
Codeine  in  V^o  to  Vi^-grain  doses,  repeated  every  two  or  three  hours,  can 


74G  DISEASES    OF    THE    BLOOD. 

be  given  until  the  pain  ceases.  In  some  cases  chloral  hydrate  combined 
Nvith  bromide  of  sodium  will  alt'ord  relief.  Eubbing  the  affected  muscles 
with  ol.  hj^oscyamus  seems  to  relieve. 

Torticollis  (Wry-xeck). 

This  condition  is  caused  by  the  spasm  of  one  sterno-cleido-mastoid 
muscle.  Sometimes  there  may  Ije  a  spasm  of  tlie  posterior  cervical  muscle, 
including  the  trapezius. 

Etiology. — Congenital  torticollis  is  a  rare  condition.  When  it  is 
present  it  is  due,  according  to  Whitman,  to  a  constrained  condition  in 
utero. 

More  common  than  the  congenital  condition  is  the  acquired  torticollis. 
The  following  is  Whitman's  classification : — 

1.  The  acute.  3.  The  chronic. 

Acute  torticollis  (traumatic  torticollis)  may  be  divided  into  three 
classes : — 

(a)  "Stiff  neck,"  due  to  "cold"  or  to  rheumatism. 

(b)  Distortion  caused  by  strain  or  other  injuries. 

(c)  Distortion  due  to  irritation  of  the  peripheral  nerves  as  following 
"sore  throat,"  or  secondary,  to  enlarged  or  sui)purating  cervical  glands,  and 
the  like  ("reflex  torticollis"). 

The  ordinary  stiff-neck  is  of  but  slight  importance.  The  traumatic 
wry-neck  is  efficiently  treated  by  support.  Eeflex  torticollis  is  by  far  the 
most  important  of  the  forms  of  acute  torticollis,  and  it  is  the  usual  cause 
of  persistent  distortion. 

Chronic  Torticollis. — From  the  clinical  standpoint,  both  the  congenital 
and  the  reflex  torticollis,  after  the  acute  stage  has  passed,  are  forms  of 
chronic  torticollis;  the  class  includes  also  those  forms  in  which  the  onset 
has  not  been  accompanied  hy  pain. 

Kachitic  torticollis,  usually  a  postural  or  compensatory  distortion 
caused  by  deformity  of  the  spine. 

Ocular  torticollis,  caused  by  defective  eyesight. 

Psychical  torticollis,  a  functional  or  hysterical  deformity. 

Spasmodic  torticollis,  a  convulsive  tic — rather  a  form  of  nervous  dis- 
ease than  a  simple  deformity. 

Any  irritation  of  the  spinal  accessory  nerve  or  its  branches  may  bring 
on  this  spasn).  Whitman^  gives  the  following  statistics  of  264  cases  ex- 
tending over  nineteen  years,  torticollis  from  Pott's  disease  not  being  in- 
cluded :  Males,  109;  females,  155;  congenital.  '.Vi;  under  2  years,  38; 
from  2  to  10  years,  153;  over  10  years,  46;  acute  (less  than  two  months' 


*  Report  for  Hospital  of  Ruptured  and  Crippled,  New  York. 


PURPURA.  747 

duration),  T7;  clirouic,  GO,  of,  which  uuinher  22  had  lasted  over  two  years 
or  longer. 

Holt  believes  that  an  enlarged  cervical  lymph  gland  irritating  the 
spinal  accessory  nerve  can  bring  on  this  spasm.  He  also  mentions  malaria 
as  a  cause.  I  have  observed  similar  conditions.  In  several  of  my  cases 
the  spasm  was  present  when  malarial  infection  existed,  and  subsided  when 
quinine  was  given.  Torticollis  has  also  been  observed  by  me  after  the 
sudden  chilling  of  the  body. 

Symptoms. — The  head  is  drawn  to  the  affected  side.  If  the  trapezius 
is  affected  there  is  slight  rotation  of  the  head,  but  if  the  trapezius  is  not 
affected  the  head  is  rotated  toward  the  healthy  side. 

A  child  G  years  old  was  taken  on  an  open  car.  She  was  in  a  healthy  condition, 
apj>etite  good,  bowels  regular,  apparently  notliing  wrong.  She  complained  of  being 
cold  and  on  the  following  day  had  a  wry-neck.  Salicylate  of  soda,  in  5-grain  doses 
three  times  a  day,  and  massage  of  the  sterno-cleido-mastoid  with  spirits  of  camphor 
seemed  to  relieve  the  pain.  The  best  result  was  obtained  by  the  use  of  a  mild 
fara<lic  current.  The  condition  lasted  about  nine  days.  The  child  was  discharged 
cured. 

The  above  case  illustrates  the  form  commonl}-  described  as  rheuma- 
tism or  "rheumatic  torticollis." 

Treatment. — Medicinal  and  Local:  Early  treatment  means  success. 
Delayed  treatment  means  disappointment  in  most  instances.  When  specific 
causes  exist,  such  as  malaria  or  rheumatism,  they  should  be  treated  by 
specific  remedies.  In  every  case  warmth,  as  flaxseed  poulticing  and  mas- 
sage, will  do  good.  (Sometimes  the  ap])lication  of  iodine  over  the  affected 
muscles  will  do  good. 

^urcjical  Treatment. — Lorenz  describes  the  fine  results  attained  by  sub- 
cutaneous intentional  rupture  of  tiie  sterno-cleido-mastoid  muscle  to  cure 
obstinate  svry-neck  in  children.  The  sul^ject  lies  with  a  hard  cushion  under 
the  shoulders,  the  head  and  neck  unsupported.  The  shoulder  is  drawn  down 
at  the  same  time  and  it  is  thus  possible  to  tear  the  muscle  by  gradual  de- 
hiscence, followed  by  over-correction.  Parents  accept  this  operation  much 
more  readily  than  when  the  knife  is  used,  and  the  dehiscent  fibers  heal 
under  the  intact  skin  with  little  if  any  cicatricial  formation.  The  cure  has 
been  ideal  and  ])ermanent  in  all  his  cases. 

PriUTH.V. 

HaMuorrhages  into  the  skin  or  mucous  membrane  are  designated  as 
])urpura.  ^^'h('n  small  they  are  called  |)('tecliial :  when  large  tlu>v  are  called 
ecchymoscs.      Pui-pura  is  frecincntly  as^ociated  with  the  infectious  diseases. 

^fartlia  T5..  7  years  old,  was  l)ronght  <o  the  Willard  Parker  Hospital  ,\ugnst  31. 
l!)().'i.  She  had  l)oen  ill  two  days  before  admission.  The  diagnosis  of  nasal  diphtheria 
was  made.  On  admission  the  pulse  was  158.  Two  days  later  it  dropped  to  flO,  and 
on  the  third  day  (he  pnlse-rate  sank  from  OC  to  W.      A  genera]  pnrpnrn  was  notii-e- 


748 


DISEASES    OF    THE    BLOOD. 


tgax. 

DATES  OF  OBSERVATIONS          | 

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able.  There  were  bluish  diseolorations  of  the  skin  visible  on  the  extremities.  Dr. 
Burckhalter,  the  resident  physician,  called  my  attention  to  a  haematuria.  The  case 
ended  fatally. 

Purpura  HiEMORRHAGiCA  (Morbus 
Maculosus  Werlhofii.) 

This  is  the  most  severe  form  of 
piirpma.  The  lesions  are  a  series  of 
haemorrhages  confined  to  the  mucous 
membrane  and  skin.  On  the  skin 
purpuric  spots  are  seen  which  de- 
note hciemorrhages.  These  hsemor- 
rhages  are  seen  in  the  lower  and  up- 
per extremities ;  also  on  the  face  and 
abdomen.  The  conjunctival  mu- 
cous membrane  shows  ecchymotic 
areas.  The  gums  bleed  easily  and 
there  are  hgemorrhagic  areas  on  the 
soft  and  hard  palate.  Ha?maturia 
and  haemoptysis  are  sometimes  seen. 
Diagnosis. — The  only  disease 
that  might  be  taken  for  purpura  is 
scurvy,  but  the  general  history  of 
the  case  associated  with  malnutri- 
tion will  clear  up  any  doubt. 
Treatment. — Eest,  iron,  small  doses  of  ergot  and  hydrastis  internally, 

lemons,  oranges,  and  a  nutritious  diet.     Aromatic  sulphuric  acid  in  5-drop 

doses,  several  times  a  day,  should  be  remembered. 

Purpura  Kheumatica  (Peliosis  Rheumatica:    Schonlein's  Disease). 

The  association  of  haemorrhages  with  affections  of  the  joints  charac- 
terizes this  disease.  It  has  frequently  been  noted  that  there  is  tenderness 
in  the  joints  during  the  course  of  simple  purpura.  But  the  more  pro- 
nounced form  of  fever,  in  conjunction  with  swellings  and  tenderness  of 
tlie  joints,  plus  the  characteristic  appearance  of  the  subcutaneous  haemor- 
rhages appearing  in  purpuric  spots,  differentiate  peliosis  from  simple  pur- 
pura. 

Associated  with  this  rheumatic  affection  we  frequently  have  extravasa- 
tions of  blood  and  serous  effusions  into  the  joints,  giving  a  decided  fluc- 
tuating feeling.  One  very  important  ])oint  is  the  fact  that  cardiac  lesions 
do  not  complicate  this  condition.  Ca.ses  of  this  kind  have  frequently  been 
reported,  and  Baginsky  lays  stress  on  the  non-existence  of  heart  lesions 
in  this  affection. 


Fig.  234. — ^lalignant  Purpura  Compli- 
cating Nasal  Diphtheria.  General  sepsis. 
Toxic  Nephritis,  meningitis,  myocarditis. 
Note  pulse.     Fatal.      (Original.) 


PURPURA.  749 

The  following  case  came  under  my  observation^ : — 

A  child,  George  P.,  about  9  years  old,  was  attacked  with  pains  in  his  feet  and 
cried  when  attempting  to  walk.  He  had  had  some  very  violent  exercise  during  the 
four  or  five  weeks  jireceding  this  attack  by  riding  a  bicycle  as  much  as  four  and  five 
hours  daily.  The  mother  stated  to  me  that  he  had  frequently  complained  of  joint 
pains,  but  she  attributed  them  to  "growing."'  She  noted,  however,  that  after  bicycle 
riding  the  boy"s  pain  was  much  more  intense.  His  general  condition  was  otherwise 
healthy.      The  examination  gave  me  the  following  status: — 

A  very  well  nourished  boy:  muscular  and  adipose  tissues  quite  well  developed, 
and  very  tall  for  his  age.  His  weight  was  84  pounds.  The  examination  of  the 
thorax  showed  both  heart  and  lungs  normal;  no  cough;  heart  sounds  regular, 
strong;  pulse,  96.  The  temperature  was  100.2  in  the  rectum,  and  respiration  30. 
The  tongue  was  slightly  coated ;  appetite  good ;  bowels  always  inclined  to  constipa- 
tion; but  recently  since  riding  the  bicycle,  very  much  improved.  Intellect  free,  and 
the  boy'  is  mentally  well  developed. 

The  examination  of  the  joints  showed  severe  tenderness  and  swelling  in  both 
knees  and  ankles;  slight  2)ain  on  palpating  or  rotating  the  hip  joint.  The  most 
marked  tenderness  and  swelling  was  found  at  the  knee  joints.  The  upper  extremi- 
ties— shoulder,  elbow  and  wrist — were  perfectly  normal,  as  far  as  palpation  and 
inspection  could  demonstrate.  The  eruption  on  the  skin  was  of  a  purplish  or  bluish 
color,  and  looked  like  a  distinct  subcutaneous  haemorrhage.  It  was  confined  to  the 
lower  extremities,  covering  almost  completely  the  inner  portions  of  both  thighs,  the 
ankles,  and  more  especially  the  calves  of  both  legs.  The  spots  were  very  irregular  in 
outline,  in  some  places  confluent,  resembling  more  particularly  the  eruption  of 
morbilli. 

The  child  was  put  to  bed,  the  joints  were  rendered  immobile  by  applying  woolen 
roller  bandages  over  them,  and  locally  over  each  joint  some  salicylic  collodion,  10  per 
cent.,  was  applied  with  a  camel's-hair  brush. 

The  main  point  in  the  treatment  which  I  laid  stress  upon  was  to  have  absolute 
rest,  and  it  was  for  this  reason  that  I  put  the  child  to  bed,  that  I  painted  salicylic 
collodion,  and  that  I  put  a  roller  (flannel)  bandage  on  the  legs  and  covered  both 
limbs  from  the  toes  to  the  hip  joint.  Internally  I  gave  ergotine,  Vso  gi'ain  every  four 
hours,  besides  15  drops  of  tinct.  ferri  acet.  seth.  in  water  after  each  meal,  three 
times  a  day.  The  spots  gradually  changed  from  a  deep  bluish  color  to  a  brown; 
then  after  ten  days  to  a  light  yellowish  color,  and  after  twenty-seven  days  they  could 
scarcely  be  seen  with  the  naked  eye. 

This  case  has  a  very  interesting  clinical  history.  The  question  that  arose  in 
my  mind  was:  Did  the  violent  exercise  on  the  bicycle  cause  the  inflammation  of 
the  joints  and  possibly  also  the  subcutaneous  haemorrhages?  On  looking  over  the 
previous  history  of  the  child,  I  found  that  he  had  been  well  nourished,  breast-fel 
until  eleven  months,  and  then  weaned;  commenced  walking  at  1  year,  and  talking  at 
same  age.  Dentition  began  at  seven  months,  and  when  eight  months  had  two  lower 
and  two  upper  incisors;  the  child  had  seven  teeth  at  eleven  months,  at  time  of  wean- 
ing. 

There  is  no  sign  of  rickets,  although  there  is  a  large  belly,  rather  pendulous, 
and  the  previous  history  of  constipation.  The  ribs  are  normal,  the  long  bones  well 
developed;  spine  and  thorax  as  good  as  desired.  I  could  obtain  no  data  concerning 
time  of  closure  of  fontanels.  There  is  no  history  of  hiT-mophilia ;  no  previous  l)1ee(l- 
ing;     no   epistaxis;     no   hsemoptysis;     both   parents   of   the   child   living,  and   both 


'  Pediatrics,  vol.  ix,  No.  10,  1900. 


750  DISEASES    OF    THE    BLOOD. 

Iioalthy.  Tlio  cliihl  lias  luid  measles,  complicated  with  bioncliitis,  when  3  years  o'd. 
lastinj,'  ill  all  about  one  month.  No  disease  previous  to  tliis;  no  summer  complaint, 
and  nothing;  since  that  time. 

There  is  no  evidence  of  scurvy;  teeth  are  well  developed,  perfectly  normal;  the 
gums  are  healthy.  The  mother  had  two  other  children — one  now  nursing  and  one 
4V2  years  old.     She  has  had  no  miscan-iages ;    no  reason  to  suspect  lues. 

I  believe  the  etiological  factor  in  this  case  was  the  traumatic  element,  namely, 
the  violent  exercise  causing  both  the  luemorrhages  and  the  iiillainmatory  affection  of 
the  joints. 

Henocil's  Purpura. 

Ha?inorrhagic  areas  confined  to  the  abdomen  and  lower  extremities 
are  sometimes  seen.  There  is  also  vomiting  and  abdominal  symptoms, 
such  as  diarrhtea  (bloody  stools)  and  colicky  pains.  There  is  marked 
distension  of  the  abdomen  and  pains  in  the  joints.  This  condition 
resembles  that  which  has  already  l)een  described  in  the  article  on  "Purpura 
liheumatica." 

LlTH.l-miA    ( IjUniURIA) . 

Haig  and  Rachford  have  given  us  a  very  clear  conception  of  this  con- 
dition, which  is  simply  an  excess  of  uric  (lithic)  acid  in  the  blood.  Haig 
designates  this  condition  as  uricacida'iuia.  Otlier  writers  call  it  lithuria. 
Eachford  calls  this  "leucomain  poisoning." 

Etiology. — AVhen  this  condition  is  met  with  in  children,  we  can  usually 
look  to  the  litha?mic  ancestors  for  the  origin  of  the  disease.  Imprudent 
diet,  such  as  excess  of  proteids,  may  be  a  factor.  Sedentary  life  and  lack 
of  proper  metabolism  invite  this  condition.  The  alloxuric  bodies  are  ex- 
creted by  the  skin,  kidneys,  and  intestinal  canal.  These  bodies  are  removed 
by  the  kidney  cells  from  the  blood  into  the  urine.  ^Yhen  they  are  in  excess 
they  must,  therefore,  have  been  present  in  solution  in  the  blood  before  their 
elimination. 

The  presence  of  uric  or  lithic  ticid,  xanthin,  hypoxanthin,  hetero- 
xanthin,  and  paroxanthin  are  the  factors  causing  this  trouble.  We  are 
still  in  the  dark  concerning  the  manner  in  which  these  bodies  act. 

If  the  kidneys  are  diseased  these  bodies  are  retained  and  the  skin  is 
called  upon  to  do  the  work  which  the  kidneys  fail  to  do.  Thus  it  is  that 
hot  baths  which  jiromote  diaphoresis  eliminate  through  the  skin,  in  addi- 
tion to  stimulating  the  action  of  the  kidneys. 

Symptoms. — The  new-born  litha?mic  infant  frequently  eliminates  an 
excess  of  urates  during  the  first  few  d;iys  of  life.  In  such  infants  crystals 
of  uric  acid  may  be  precipitated  into  the  tubules  of  the  pyramids  of  the 
kidney.  Jacobi  says  that  these  uric  acid  infarctions  may  subsequently  be 
washed  out  of  the  tubules  and  serve  as  the  nuclei  of  urinary  calculi. 

Nocturnal  incontinence  is  frequently  a  symptom  of  lithsemia.     True 


PLATE  XXII 


Henoch's  Purpura.     Note  ecchyinotic  spots  on  lower 
extremities.      (Original.) 


I 


i 


LITH.^MIA.  751 

arthritic  gout  resulting  from  iiratic  deposits  in  the  tissues  about  the  joints 
is  very  rare  in  cliildlKxxL 

Fever,  crying  while  the  ehikl  passes  ur'ne,  scanty  urine  whieli  usually 
deposits  a  reddish  sand  on  the  diaper,  and  irritation  of  the  external  genitals 
are  the  symptoms  which  appear  at  tlie  time  of  urination.  The  urine  is 
very  acid  and  we  speak  of  this  condition  as  "a  uric  acid  form  of  litliiemia." 
Sometimes  tliere  are  gastro-enteric  numifestations,  sucli  as  vomiting,  head- 
ache, gastric  pain,  convulsions,  a  sickening  odor  of  tlie  breath,  and  consti- 
pation. These  gastric  symptoms  bear  no  relation  to  improper  diet.  They 
are  usually  met  with  in  children  who  are  carefully  guarded  as  to  the  diet. 
Such  children  are  extremely  nervous  and.  irritable.  Eczema  is  a  very  com- 
mon manifestation  of  this  condition.  Unless  a  proper  understanding  of 
this  condition  exists  it  will  persist  and  be  difficult  to  relieve. 

The  urine  in  Uihcemia  is  high  colored;  the  specific  gravity  increased. 
On  standing,  there  is  a  sediment  of  red  sand  (urates).  If  the  urine  is 
examined  immediately  after  a  paroxysm  then  the  poisonous  xanthin  bodies 
previoi'"'ly  mentioned  may  be  found  present.  Transient  albuminuria  is 
occasionally  met  with. 

Treatment. — 'I'he  diet  is  the  most  important  part  of  the  treatment. 
Cereals  must  be  given ;  beef  juice,  soups,  broths,  and  fruits.  No  alcoholics 
should  be  given;  in  fact,  all  rich  and  heavy  articles  of  food  must  be  ex- 
cluded. Meat  must  be  given  sparingly.  Salads  and  gravies  are  objection- 
able. Infants  require  massage.  This  passive  form  of  exercise  will  stim- 
ulate the  circulation.  If  children  are  old  enough  to  exercise,  then  exercise 
should  form  an  important  part  of  the  treatment. 

Drug  Treatment. — Calomel  should  always  be  given  in  the  commence- 
ment of  the  treatment.  We  must  aid  in  keeping  the  bowels  loose  during 
the  whole  course  of  treatment. 

Salicylate  of  soda  and  salol  arc  useful  eliminatives.  Phosphate  of 
sodium  and  benzoate,  especially  if  eczema  exists,  are  valuable.  Alkaline 
waters,  such  as  white  rock  and  apoUinaris,  may  be  given  ad  libitum. 
The  Carlsbad  waters  have  the  same  eliminative  effect.  Dilute  hydrochloric 
acid  or  dilute  phosphoric  acid  in  3  to  5-drop  doses  before  meals  is  es- 
pecially indicated  when  severe  headache  and  gastric  symptoms  exist. 
Urotropin  in  2-grain  doses  may  be  given  in  tablet  form. 

H.'E-MOI'IIILIA. 

This  is  usually  an  inlierited  condition.  It  is  characterized  by  a  ten- 
dency to  l)leed,  lience  the  term  "bleeder"'  is  apfjlied  to  this  class  of  cases. 
Whole  families  are  found  in  which  this  tendency  to  bleed  exists. 

Pathology. — The  walls  of  the  blood-vessels  show  no  alteration,  citlier 
macrosco])ically  or  microscopically.  "The  swelling  of  the  joints  is  due  to 
hannorrhages  into  the  articulations  and  into  the  surrounding  tissues.     The 


752  DISEASES    OF    THE    1?IX)0D. 

tissues  aro  l)]anc']K'(l  from  loss  of  blood."  I'hc  siiriace  of  the  body  shows 
petec'hia>  or  hrnisod  patclics.  ■ 

Symptoms.- — The  appearance  oi'  the  ehiki  does  not  always  disclose  the 
tendency  lo  bleed,  it  is  only  when  an  operation  is  performed  or  aii  in- 
jury exists  that  alarming  and  frecjuently  fatal  Iia3ni0irrhages  are  seen. 
Epistaxis  is  the  most  common  symptom  noted.  Swelling  of  the  joints 
resembling  rheumatism  is  frequently  seen.  The  bleeding  takes  place 
from  the  capillaries,  most  often  an  oozing  which  may  continue  for  weeks. 
The  subjects  of  haemophilia  are  sensitive  to  cold. 

In  the  chapter  on  "Syphilis''  1  have  already  described  a  case  of  bleed- 
ing in  which  the  lesions  of  syphilis  w(>re  present. 

Annie  G.,  13  years  old,  was  breast-fed  in  infancy.  She  had  diphtheria  when 
1  year  old.  Had  pertussis  wlien  2  years  old,  which  lasted  nine  weeks.  HaB  had 
pneumonia  twice.  No  history  of  rlioinnatism  given  and  has  had  no  other  infectious 
disease. 

History  of  Jilvcdiinj. — Has  always  been  tioubled  with  liaMnorrhages.  The  nose 
bleeds  at  the  slightest  provocation.  Blood  spitting  is  quite  common.  The  slightest 
irritation  of  the  bowels  with  looseness  is  associated  with  blood  in  the  stools.  Large 
varicose  veins  are  found  over  the  legs.  There  are  a  nmnber  of  scattered  nsevi.  Not 
infrequently  the  veins  of  the  legs  bleed  daily  for  a  i>eriod  of  twenty  or  thirty  days. 

The  Heart. — There  is  a  loud  systolic  murmur  heard  in  front  and  behind,  and 
transmitted  to  the  side.  This  endocarditis  is  a  sequela  to  the  attack  of  diphtheria. 
The  child's  weight  when  seen  by  nie  was  67  povmds.  Stypticin  seemed  to  do  more 
good  than  ergot  internally.  Hydrastinine  hydrochlorate,  Ve  grain  three  times  a  day, 
seemed  to  check  the  bleeding  during  another  attack.  When  laat  seen  by  me  the  child 
was  developing  fairly  well. 

Prognosis. — This  depends  on  the  frequency  of  the  haemorrhages  and 
the  child's  general  condition.  In  152  cases  reported  by  Grandidicr  more 
than  one-half  died  before  completing  the  seventh  year,  and  only  nineteen 
attained  majority.^ 

Treatment. — All  operations,  no  matter  how  slight,  should  be  avoided 
if  possible.  Even  the  extraction  of  a  tooth  must  be  seriously  considered, 
owing  to  the  danger  of  bleeding. 

The  diet  should  consist  principally  of  vegetables  and  fruits.  When 
bleeding  occurs,  immediate  treatment,  consisting  of  ice  and  Monsell's  solu- 
tion, should  be  used  locally.  Jnternally,  gallic  acid  and  hydrastine, 
Vs  grain,  repeated  every  three  or  four  hours.  If  intestinal  haemorrhage 
exists,  colon  flushings  of  tepid  water,  temperature  of  80°  F.,  containing 
1  drachm  of  alum  to  1  pint  of  water,  may  be  tried.  Ice  water  is  also 
recommended  for  the  same  purpose. 

The  injection  of  15  to  30  cubic  centimeters  of  sterile  horse  serum  is  an 
excellent  hannostatic.  In  the  case  of  a  "bleeder,"  recently  seen  by  me  in 
the  Babies'  Wards  of  the  Sydenham  Hospital,  one  injection  of  horse  serum 
controlled  the  haemorrhage  due  to  a  paracentesis,  after  all  local  means  failed. 


1  See  article  in  "Starr's  Text-book." 


CHAPTEE  IV. 
DISEASES  OF  THE  GLANDS  OR  LYMPH  NODES. 

The  Thymus  Glaxd. 

This  long  lobulated  gland  is  similar  in  structure  to  the  salivary  glands. 
It  lies  in  tlie  anterior  mediastinum,  immediately  behind  the  manubrium 
of  the  sternum.  The  thymus  reaches  its  full  development  during  the  second 
year,  after  which  it  gradually  disappears.  The  function  of  the  thymus  is 
still  a  question,  although  it  is  believed  to  have  a  function  similar  to  the 
spleen.  Sudden  death  has  frequently  been  attributed  to  an  enlarged  thy- 
mus. Tuberculosis  involving  the  thymus  gland  is  occasionally  seen  in  cur- 
rent literature. 

Status  Lymphaticus. 

This  condition  is  found  in  rachitic  children,  and  is  of  especial  interest 
because  of  the  enlarged  glands  at  the  angle  of  the  jaw  in  addition  to  the 
adenoids  in  the  vault  of  the  pharynx,  and  enlargement  of  the  lingual  tonsil. 

The  cervical,  bronchial,  axillary,  or  the  inguinal  glands  are  enlarged. 
There  is  also  a  tendency  to  swelling  of  the  parts.  Enlarged  lymph  nodes 
at  the  angle  of  the  jaw  and  hyperplasia  of  the  connective  tissue  of  the  nose 
and  pharynx  are  seen. 

The  tliymus  gland  is  very  much  swollen,  and  this  is  believed  to  be  the 
cause  of  sudden  death  in  many  cases. 

Escher'ch  believes  that  the  pathological  condition  of  the  thymus  gland 
causes  a  form  of  acute  intoxication  resulting  in  cardiac  syncope  and  paral- 
ysis.    This  condition  must  not  be  confounded  with  scrofulosis. 

Escherich  lias  reported  a  case  in  which  laryngeal  spasm  occurred  thirty 
times  a  day.  In  such  cases  the  danger  of  asphyxia  should  be  borne  in  mind. 
The  condition  is  of  im])ortance  because  of  the  danger  involved  during  the 
administration  of  an  ana-sthetic. 

The  following  case  was  seen  by  mo  in  consultation  with  Dr.  A.  W. 
Newfield  during  the  summer  of  1904  : — 

The  infant  was  breast-fp<l,  l)ut  did  not  seem  to  nurse  well.  Tlie  lymph  nodes  at 
the  angle  of  the  jaw.  the  groin,  axilla,  and  various  portions  of  the  scalp  could  be 
plainly  felt.  Tlie  child  had  laryngeal  spasms.  Had  had  as  many  as  twenty-five  or 
thirty  attacks  of  laryngismus  stridulus.  The  adenoid  tissue  at  the  base  of  the 
tongue  was  enlarge<l.  There  was  also  a  mass  of  adenoids  in  the  posterior  nares. 
Tiu'  posterior  j)lmryngeal  wall  was  studded  with  fungous  granulations.  The  infant 
had  a  very  short,  thick  neck.  Tlie  nurse  in  charge  was  always  afraid  the  infant 
would  die  during  these  spasms.      It  wa-s  necessary  to  gavage  to  sustain  life.      By 

*«  (753) 


754  DISEASES  OF  THE  CI.AXDS  OR   EVMPTT   NODES. 

pumping  some  of   the  breast-milk  and  using  cows"  milk  for  alternate  feedings  we 
gradually  strcngtlieninl  the  infant. 

C'odliver-oil  inunrtiuns  were  ordertM.1  to  aid  in  the  nutrition  of  the  body. 

When  such  a  fondition  is  i'ound  great  care  must  be  exercised  so  as  not 
to  lower  the  vitality  of  the  j^atient,  but  rather  to  stinnilate  nutrition  by 
•giving  arsenic  in  the  form  of  Fowler's  solution  in  addition  to  iodide  of 
sodium. 

AcuTK  Adenitis. 

This  inflannnatory  condition  of  tlie  lymphatics  is  quite  common.  It 
is  usually  caused  by  an  infection,  or  an  abrasion  of  the  skin,  permitting  an 
infection  in  or  about  the  glands  affected. 

The  cervical  glands  are  most  frequently  affected. 

Inflammatory  conditions  in  the  nose,  throat,  the  mouth,  or  on  the 
skin  give  rise  to  tiiese  swellings. 

The  axillary  glands  are  frequently  swollen,  due  to  septic  absorption 
following  vaccination. 

The  glands  of  the  thigh  and  the  inguinal  glands  are  commonly  affected 
when  there  are  irritations  or  inflammatory  lesions  involving  the  genitals, 
or  the  lower  extremities. 

Pathology. — The  glands  show  swelling  and  infiltration  with  inflam- 
matory products.  The  immediate  tissues  are  usually  involved.  Very  fre- 
quently the  swollen  glands  resolve.  At  other  tiuu's  there  is  an  excessive 
migration  of  white  cells  so  that  tlie  glands  break  down  and  abscess  results. 

Symptoms. — The  glands  per  sc  uuiy  show  inflamnuitory  symptoms,  such 
as  fever,  tenderness,  and  swelling.  It  is  wise  to  examine  the  adjacent  parts 
to  ])e  sure  that  the  glands  are  not  a  secondary  inflammatory  condition.  For 
example,  in  di])htheria  the  neighboring  glands  are  usually  swollen.  If  the 
gland  only  is  involved,  we  have  no  evidence  of  reddening  or  inflammation. 
When  inflammation  exists  involving  the  neighboring  tissues,  a  reddening 
of  the  skin  takes  place.  Such  cases  usually  have  fluctuations,  or  soft  areas 
can  ])e  made  out.  The  glands  are  swollen,  at  times  reaching  the  size  of  a 
hen's  egg. 

The  diagnosis  is  very  easily  made. 

The  prognosis  depends  on  the  condition  of  the  child  at  the  time  of 
infection.  If  tuberculosis  exists,  the  prognosis  i^  had.  The  prognosis  of 
acute  adenitis  in  conjunction  with  acute  exanthemata  is  usually  good. 

Treatment. —  (a)   Ahortivc ;    (b)   surgical. 

Abortive.- — The  inunction  of  Crede  ointment  has  served  me  very  well. 
A  piece  of  the  salve  about  tbe  size  of  a  bean  should  be  well  rubbed  into 
the  swollen  gland.  'I'he  rubl)ing  should  be  continued  at  least  ten  minutes. 
Sometimes  a  leech  applied  to  a  gland  will  reduce  the  swelling.  An  ice-bag 
will  reduce  swelling  and  sometimes  prevent  suppuration.  Belladonna  oint- 
ment and  ichthyol,  10  per  cent.,  with  lanoline  is  sometimes  useful. 


ADENITIS.  755 

Surgical  Treatment. — When  tluetuation  is  felt,  hot  fomentations  with 
flaxseed  meal  will  be  very  grateful.  An  ineision  should  be  made,  with 
aseptic  detail,  pus  evacuated,  and  the  wound  packed  with  iodoform  gauze. 

Later  restorative  treatment,  such  as  malt,  iron,  codliver-oil,  or  the 
syrup  of  the  iodide  of  iron,  shouUl  be  given. 

CiiROxic  Adenitis. 

Not  infrequently  we  meet  with  children  who  have  swollen  glands  last- 
ing months  and  years,  in  whom  no  evidence  of  tuberculosis  or  syphilis 
exists. 

This  is  usually  due  to  repeated  attacks  of  inflammation  following 
acute  adenitis,  or  it  is  the  result  of  chronic  inflammation  of  the  skin. 

Pathology. — The  glands  show  an  increase  in  their  cellular  and  con- 
nective tissue  elements.     They  undergo  a  true  hyperplasia. 

Symptoms. — The  symptoms  consist  in  a  sweKing  of  the  glands  without 
inflammation  or  tenderness.  In  chronic  adenitis  the  glands  do  not  break 
down,  hence  suppuration  is  absent.  In  conjunction  with  chronic  enlarged 
glands  we  find  hyperplasia  of  the  tonsils,  so  that  we  invariably  have  en- 
larged tonsils  and  adenoids  in  such  conditions. 

Diagnosis. — The  diagnosis  should  be  made  after  syphilis,  tul)erculosis, 
and  other  infections,  such  as  diphtheria  and  scarlet  fever,  have  been  ex- 
cluded, so  that  we  can  be  sure  no  specific  or  infectious  disease  is  the  origin 
of  the  trouble. 

The  prognosis  is  usually  very  good. 

Treatment. — The  treatment  consists  in  removing  the  cause.  Middle 
ear  inflammation,  scalp  disease,  and  pediculosis  should  be  vigorously  treated. 
Adenoids  and  diseased  tonsils  should  be  removed.  Thus  the  treatment  is 
narrowed  down  to  removing  the  cause  if  possible  and  relying  on  restorative 
treatment,  fresh  air,  and  good  nutrition. 

Tubercular  Adenitis. 

This  condition  is  due  to  an  invasion  of  the  tubercle  bacillus,  resulting 
in  a  tubercular  numifestation  of  the  glands.  It  was  fornu>rly  believed  to 
be  "scrofulosis."  The  pharynx  and  tonsils  seem  to  be  the  point  of  entrance, 
as  the  glands  in  the  cervical  region  are  usually  aft'ected. 

Pathology. — 'Hie  glands  undergo  a  caseous  degeneration  which  fre- 
(piently  results  in  abscess.  At  times  we  meet  with  tub'ercular  lesions  in 
\arious  organs  of  the  body.  In  the  glands  we  note  that  they  are  studded 
with  miliary  tubercles  and  also  find  the  tul)ercle  bacillus  therein. 

Symptoms. — The  glands  enlarge  in  various  parts  of  the  body;  most 
frc(iuently  the  cervical  glands  are  affected.  It  is  usually  a  very  slow  process, 
extending  over  months;  sometimes  years.  During. this  time,  from  the  long 
continued  inflamnuition,  evidence  of  a  continued  illness  is  shown.     When 


756 


DISEASES  UE  THE  GILAXDS  OR  EWMTII   .NODES. 


these  abscesses  form  they  heal  ver}-  slowh-  and  friMjuontly  k'avo  sinuses  or 
ragged  scars. 

Ili'iiry  G.,  2  V,.  j^ears  old,  was  bioiij^lil  tu  my  cliililri'irs  scrvioc  witli  a  liislory 
of  rei'urriiig  swelling  on  botii  bides  of  tlu-  neck  and  also  bL-hind  tlie  ear.  The  cliild 
was  bottle-fed  during  infancy  and  had  always  suffered  with  dyspeijtie  tnmblc  and 
constipation.  He  has  had  furuneulosis  of  the  scalp,  wliich  necessitated  incisions, 
during  tlie  sef>ond  year.  Was  troubled  with  tonsillar  and  catarrhal  trouble,  also 
double  otitis. 


Fig.  235. — Case  of  Cervical  Adenitis  in  which  a  Positive  von   Pirquet 
Reaction   Appeared.    (Original.) 

Tlie  glands  of  the  neck  are  swollen  and  fitMpiently  break'  down  and  discharge 
pus.  Tlie  temperature  is  not  elevated.  This  snp])uration  is  known  as  the  vuUl  (ibsn  ss 
type.  The  general  condition  is  fair.  The  child  is  taking  nialtine  with  liypoplios- 
phites.  A  restorative  diet  of  cereals,  cream,  butter,  eggs,  etc.,  is  gi\en.  Attention  to 
hygiene,  and  out-door  life  is  the  most  ii)ii)ortant  part  of  the  treatuvnt. 

Diagpiosis. — Tliis  can  easily  be  made  wlien  we  consider  the  character 
of  the  glandular  swelling,  tlieir  tendency  to  caseation,  and  to  suppuration. 
"\Mien  the  pus  is  examined,  tul:»ercle  bacilli  are  invarial)ly  found.  ■ 

Differential  Dia^osis. — Tn  the  beginning  this  disease  is  difficult  to 
diagnose.  "We  can  exclude  syphilis  by  the  history  of  the  parents.  AVheii 
the  history   is   not   ol)tainal)lo,   resorting  to   anti-syphilitic   treaiment   will 


MUMPS.  757 

materially  aid  in  eliminating  the  diagnosis  of  syphilis.  In  Hodgkin's  dis- 
ease the  glands  do  not  suppurate.  In  simple  chronic  adenitis  there  is  no 
suppuration. 

Treatment. — Attention  to  hygienic  details  is  of  prime  importance. 
The  diet  should  consist  of  restorative  foods  in  which  proteids  and  fats 
abound.  Ecstorative  medication,  such  as  iron,  codliver-oil,  iodide  of 
sodium,  and  arsenic,  and  syrup  of  iodide  of  iron  are  the  most  useful  drugs 
to  be  considered. 

Eead  also  tlie  treatment  outlined  in  the  chapter  on  "Acute  Miliary 
Tuberculosis." 

The  surgical  treatment  of  tubercular  adenitis  should  consist  in  the 
total  removal  of  the  suppurating  glands,  using  aseptic  precaution,  rather 
than  to  rely  on  slow  spontaneous  evacuation  of  pus  l)y  Nature. 

Mumps  (Specific  Parotitis). 

This  is  a  specific  febrile  disease,  characterized  by  inflammation  of  the 
salivary  glands. 

Etiology. — This  disease  is  prevalent  all  over  the  w^orld,  occurring 
usually  in  the  form  of  local  epidemics.  It  is  more  marked  during  the  cold 
and  wet  seasons  than  in  the  summer.  The  disease  is  disseminated  from 
patient  to  patient  by  infectious  material.  Children  between  10  and  15 
years  of  age  suffer  most.  Boys  are  more  liable  to  be  attacked  than  girls. 
Infantile  parotitis  is  frequently  met  with.  The  nursing  infant  is  not  exempt 
from  this  condition. 

The  period  of  inculcation,  counting  from  the  exposure  to  infection 
and  the  appearance  of  the  disease,  varies  from  fourteen  to  twenty-five  days. 
It  is  usually  about  throe  weeks. 

Pathology. — The  disease  is  most  likely  due  to  an  infection  by  a  micro- 
organism.    The  salivary  glands  are  probably  the  seat  of  invasion. 

Symptoms  and  Diagnosis. — The  disease  is  preceded  by  fever  lasting  two 
or  thrcH!  days,  'j'lie  temjx'rature  may  reach  104°  F.,  although  the  usual  tem- 
perature is  about  101°  F.  The  fever  may  be  so  pronounced  that  delirium 
accompanies  the  same.  The  most  pronounced  symptom  is  pain  and  ten- 
derness in  one  parotid  gland.  The  gland  becomes  swollen.  The  swelling 
occupies  the  space  behind  the  angle  of  the  Jaw  and  below  the  ear,  spreading 
forward  on  the  cheek,  and  downward  along  the  neck.  The  edge  is  ill  de- 
fined, and  the  swelling  itself  is  doughy  to  the  touch. 

Goodhart  luis  reported  cases  in  which  the  swelling  was  severe  and  the 
])atient  breathed  with  his  mouth  open.  In  such  instances  the  tongue  is  dry 
and  brown,  but  no  serious  import  should  be  given  thereto. 

'I'he  swelling  is  confined  to  that  portion  of  the  neck  between  the  jaw 
and  the  sterno-cleido-mastoid  muscle.  The  center  of  the  swelling  is  im- 
mediately under  the  lobe  of  the  ear. 


758  DISEASES  OF  THE  GLANDS  AND  LYMPH  NODES. 

The  swelling  becomes  so  extreme  and  the  pain  so  acute  that  the  patient 
can  hardly  do  more  than  separate  the  upper  and  lower  jaw.  The  submax- 
illary gland  on  the  same  side  becomes  affected  within  a  day  or  two  and  there 
is  a  large  swelling  below  the  jaw.  Soon  afterward  the  opposite  parotid 
and  submaxillary  glands  may  also  become  involved.  Goodhart  states  that 
a  swelling  of  the  cervical  lymphatic  glands  may  be  the  only  local  signs  of 
mumps. 

There  is  usually  a  general  malaise.  The  swelling  lasts  four  or  five 
days  and  then  subsides.  Suppuration  never  results.  The  amount  of  saliva 
secreted  is  not  altered.    It  may  be  excessive  or  on  the  other  hand  diminished. 

Differential  Diagnosis. — The  glandular  swelling  in  mumps  has  fre- 
quently been  mistaken  for  diphth(!ria.  In  the  latter  disease  the  parotid 
glands  are  not  affected.  The  patient  rarely  encounters  difficulty  in  opening 
the  mouth,  even  when  the  cervical  lymph  glands  are  enlarged. 

The  differential  diagnosis  between  mumps  and  diphtheria  must  be 
made  by  a  careful  inspection  of  the  fauces  and  tonsils  and  noting  the  ab- 
sence or  presence  of  meml)rane. 

There  are  other  conditions  which  may  be  accompanied  by  parotitis. 
In  enteric  and  other  fevers  in  various  disorders  of  the  abdominal  cavity, 
one  or  both  parotids  may  be  inflamed.  In  these  conditions,  however,  sup- 
puration of  the  parotid  gland  may  ensue. 

Prognosis. — This  is  almost  always  favorable.  Goodal  and  Washbourn 
state  that  during  ten  years  in  England  and  Wales  there  were  but  eighty 
deaths  registered  among  the  entire  population.  These  authors  suspect 
diphttieria  as  the  cause  of  most  of  these  deaths,  reported  as  mumps. 

Complications. — The  most  disagreeable  coniplication  is  orchitis.  This 
usually  commences  when  the  disease  has  progressed  several  weeks.  It  is 
accompanied  by  fever,  sometiuies  chills.  The  body  of  the  testicle  and  not 
the  epidermis  is  involved.  As  a  rule  ice-bags  or  leeches  aided  by  rest  will 
relieve  this  condition.  The  attack  usually  lasts  several  days,  but  may  be 
jjrolonged  several  weeks. 

Treatment. — Local:  Hot  fomentations,  consisting  of  ground  flaxseed 
meal  to  Avhich  a  few  drops  of  laudanum  have  been  added,  are  very  grateful 
and  well  Ijorne.  They  are  to  be  applied  between  two  thicknesses  of  cheese- 
cloth. These  poultices  should  be  renewed  at  intervals  of  one-half  hour. 
Among  the  newer  local  remedies,  antiphlogistine,  warmed  and  applied  in 
the  form  of  a  salve,  has  been  advocated. 

The  occasional  ap])lication  of  a  leech  at  the  site  of  the  swollen  parotid 
will  be  found  advantageous  in  some  instaiu'os. 

An  ice-bag  can  souietimes  be  used  to  advantage.  The  local  application 
of  tincture  of  iodine  can  be  recommended. 


MUMPS.  759 

The  inunction  of: — 

IJ  Unguentum  belladonna 6  drachms 

Unguentum  hydrarg.  ciner 3  drachms 

M.     Ft.  ungt. 

To  be  rubbed  in  swollen  glands  every  three  or  four  hours,  may  be  tried. 

Another  drug  which  is  quite  serviceable  is  ichthyol,  to  be  applied  sev- 
eral times  a  day,  in  the  following  manner: — 

IJ  Ammonium  sulpho.  ichthyol 2  drachms 

Lanoline    1  ounce 

M.      Ft.  unguentum. 

To  be  thoroughly  rubbed  in  swollen  glands. 

The  local  application  of  a  5  per  cent,  iodoform  collodion  painted  over 
the  inflamed  region,  several  times  a  day,  or  a  10  per  cent,  salicylic  collodion 
applied  several  times  a  day  is  at  times  beneficial. 

The  inunction  of  a  15  per  cent,  iodide  of  potassium  ointment  will  be 
indicated  if  there  is  a  suspicion  of  syphilis  in  the  case. 

Constitutional  Treatment. — Earely  do  we  require  internal  medication 
in  this  disease.  If,  however,  there  is  high  fever,  sponging  the  surface  of 
the  body  or  cold  packs  are  indicated.  The  internal  administration  of  a  mild 
laxative,  such  as  citrate  of  magnesia,  is  grateful  and  beneficial. 

Five-grain  tablets  of  rhubarb  and  magnesia  will  be  required  if  consti- 
pation exists. 

Owing  to  the  infectious  nature  of  this  disease,  the  first  rule  should  be 
to  isolate.  Tlie  isohition  should  be  thorough  and  continued  at  least  ten 
days  from  the  beginning  of  the  illness. 


CHAPTER  y. 
DISEASES  OF  THE  DUCTLESS  GLANDS. 

Cretixism  (Myxcedematous  Idiocy — Myxcedema). 

Cretinism  is  a  form  of  idiocy  associated  witii  pachydcnnatous 
cachexia. 

Etiology. — In  my  own  cases  psychical  disturbances  in  the  mother 
seemed  to  result  in  cretinism.  Worriment  and  fright  seemed  to  have  some 
etiological  relationship  to  tlie  development  of  myxcedematous  idiocy. 

In  two  cases  of  mine  the  mother  suffered  with  mental  depression,  con- 
stant worry,  and  hysterical  symptoms  during  pregnancy. 

Pathology. — We  are  indebted  to  Fletclier  Beach  for  a  series  of  careful 
post-mortem  investigations  which  have  thrown  considerable  light  on  the 
nature  of  tiiis  disease.  "We  know  that  cretinism  is  due  to  the  absence  of 
the  internal  secretion  of  tlie  tliyroid  gUmd.  In  some  instances  tlie  glaud 
is  congenitally  absent.  Tliis  condition  also  results  when  the  thyroid  gland 
is  removed  by  surgical  means.  Tt  is  safe,  therefore,  to  assume  that  the  loss 
of  the  function  of  the  thyroid  gland  causes  cretinism. 

Holt  believes  that  cretinism  is  in  some  instances  associated  with  goiter. 
This  disease  occurs  sporadically  in  our  country. 

Symptoms. — The  characteristic  manifestations  are  very  apparent  dur- 
ing the  first  year  of  a  child's  life.  Sometimes  distinct  evidences  of  cretinism 
can  be  seen  as  early  as  the  third  month  after  birth.  The  child  is  short  in 
stature  and  light  in  weight  compared  to  the  nornuil  infant.  The  extremi- 
ties, particularly  the  fingers,  are  short  and  thick.  The  lips  are  thick.  The 
tongue  is  broad  and  thick,  and  constantly  jn'otrudes  from  the  mouth.  The 
fontanel  is  late  in  closing.  The  nose  is  broad,  flat,  and  upturned.  The 
nostrils  are  wide  open.  The  hair  is  coarse  and  straight  (straw-like).  Den- 
tition is  delayed,  and  when  the  teeth  do  a])pear  they  are  very  poorly  formed. 
The  skin  of  the  entire  body  is  thick  and  dry,  but  does  not  pit  on  pressure. 

The  infant  is  stu])id.  and  it  is  very  noticeable  that  we  are  dealing  with 
deficient  mental  derelo/jnirni. 

In  the  supra-clavicular  regions  there  are  regularly  formed  pads  of  fatty 
tissue,  so  that  the  neck  is  short  and  thick  (Tuttle).  The  thyroid  gland 
cannot  be  felt  unless  it  contains  a  tumor.  Th(>  abdomen  is  large  and 
prominent  and  an  unildl'cnl  hci'iiia   is  frequently  present. 

C*onstipation   of  a   very  obstinate  character   is  usually  met  with   and 
persists  for  a  long  time.    'I'he  temjx'i'aturc  is  subnormal.    The  thyroid  gland 
(760) 


CRETINISM. 


761 


Sporadic  Ci.ktimsm. 


Fig.  236. 
ye..rs,    : 
nal.) 


Child, 
months. 


Age  2 
(Origi- 


Fig.  237. — Sanieihild.  Seveu 
months  after  continued  thy- 
roid treatment.    (Origina  . ) 

Fig.  238.  Same  child.  Age 
3  years,  9  months.  Oiie 
year  and  seven  months  after 
c  ntiniied  thyroid  treat- 
ment.    (Original,  j 


rig  ^:» 


FiK.  2:i7 


Fig.  2:!.H 


762  DISEASES    OF    THE    Ul  CTLESS    GLAKDS. 

is  absent  or  cannot  be  felt.    In  palpating  tbe  tbyroid  region  we  can  feel  the  | 
trachea.     In  some  cases  there  is  a  hypertropliied  hypotlienar  eminence  on 
the  palms  of  the  hands.     The  face  in  all  cases  has  the  prognatbous  expres- 
sion (Koplik). 

Diagnosis. — The  value  of  an  early  diagnosis  in  this  condition  is  more 
important  tbaii  in  any  other  disease  with  which  we  are  brought  in  contact. 
The  diagnosis  can  usually  be  confirmed  after  a  short  period  of  thyroid  treat- 
ment. The  specific  results  of  treatment  are  more  a])parent  in  this  condi- 
tion than  in  any  other  infantile  derangement  with  which  we  are  con- 
fronted. 

Case  I. — Frances  F.'  was  referred  to  ine  by  Dr.  L.  F.  Haas.  She  was  the 
seventh  child  of  this  family.  All  the  other  children  were  perfectly  normal.  The 
labor  was  normal.     The  child  was  born  before  the  doctor  arrived. 

Familjj  Hixtunj. — The  father  is  healthy.  The  mother  is  strong  and  healthy. 
During  the  pregnancy  the  mother  constantly  cried  on  account  of  family  trouble- 
Her  husband  was  out  of  work.  The  mother  frequently  had  hysterics.  Simil.ir 
psychical  tlistuibances  were  never  present  while  pregnant  with  the  six  other  children, 
who  are  all  strong  and  healthy. 

Uhtonj  (liven  by  the  Mother. — The  mother  noticed  that  the  child  had  short 
limbs.  That  she  was  not  bright  mentally.  That  when  1  V2  years  old  she  could 
neither  walk,  talk,  nor  support  her  head.  The  tongue  was  very  thick  and  protruded 
almost  constantly  while  awake,  as  well  as  when  asleep.  The  hair  did  not  grow. 
The  nose  was  short  and  flattened.  The  skin  wa.s  yellowish  and  dry.  The  child  had 
a  jaundiced  appearance.  Constipation  since  birth.  The  bowels  were  moved  with 
difficulty.  The  infant  was  breast-fed  until  it  was  fifteen  months  old.  Up  to  this 
time  there  was  no  sign  of  dentition.  She  was  taken  to  the  Babies'  Hospital, 
which  necessitated  her  being  weaned  from  the  breast.  She  remained  in  the 
hospital  about  two  weeks.  When  sixteen  months  old,  one  month  aftrr  thyroid 
treatment  was  commenced,  the  first  tooth  appeared.  The  child  was  successfully 
vaccinated  at  the  end  of  the  first  year. 

During  its  first  year  and  up  to  the  time  that  it  was  taken  to  the  hospital,  it 
did  not  sufl'er  with  any  infectious  disease. 

My  first  examination  was  on  Decemljer  8,  lfl02.  The  child  at  that  time  was 
2  years,  2  months  old.      The  following  conditions  were  found:  — 

The  child  can  neither  walk  nor  talk.  The  tongue  is  very  thick  and  protitides 
constantly.  The  lips,  the  eyelids,  and  the  sldn  of  the  face  are  thickened,  coarse,  and 
rough.  The  nose  is  short  and  fiat.  The  skin  has  a  yellowish  jaundiced  appearance. 
The  fontanel  is  widely  open  both  anteriorly  and  posteriorly.  The  face  is  broad  and 
the  eyes  are  set  very  wide  apart.  There  is  a  marked  depression  on  each  side  of  the 
temporal  bone.  There  is  a  marked  frontal  ]ir()tuberance.  The  child  had  nine 
teeth  when  twenty-two  months  old.  As  previously  stated  the  first  tooth  appeared 
one  month  after  the  thyroid  treatment  was  connnenced,  or  when  the  child  was 
sixteen  months  old.  The  body  is  well  develojied — fat.  There  is  no  evidence  of 
rachitis.  The  chest  and  spine  show  evidences  of  good  nutrition.  The  length  of  the 
body  was  .50 '/s  centimeters,  or  about  20  inches.  The  secretions  of  the  body  were 
very  torpid.  Constipation  of  a  very  olistiiiate  form  was  encountered.  There  were 
several  fattv  growths  in  the  sterno-cleido-mastoid  muscle. 


'■Three  cases  of  cretinism  were  presented  by  me  at  the  Section  of  Pediatries 
of  the  New  York  Academy  of  Medicine,  February  11,  1904. 


CRETIN  LSM.  763 

Tlie  child  had  a  violent  fear  of  water,  so  nmch  so  that  the  motlier  liad  difficulty 
in  bathing  her.  The  hair  is  very  thick  and  .straw-like.  The  thyroid  gland  cannot 
be  felt. 

The  pulse  was  1)0  and  of  a  full  bounding  character.  There  was  a  subnormal 
teniperatuie  which  was  never  higher  than  9S°  F.  in  the  rectum  in  the  evening. 
Respiration  was  16  while  quiet  and  24  wliile  crying.  The  urine  showed  traces  of 
indican,  evidently  due  to  the  constipation.  No  albumin  or  sugar  was  found.  Micro- 
scopically no  uric  acid  crystals;    no  casts,  and  no  bacteria  were  found. 

When  the  treatment  was  first  commenced,  1  grain  of  thyroid  was  given  three 
times  a  day.  This  dose  was  rapidly  increased  so  that  after  tlie  first  week  the  child 
took  2  V2  grains  three  tmies  a  day.  The  heart  Avas  carefully  watched  and  no 
disturbance  noted  from  the  quantity  of  thyroid  given.  In  addition,  10  drops  of 
pure  codliver-oil  was  given  three  times  a  day.  Cereals,  milk,  chicken  soup,  broths, 
and  acid  fruits,  such  as  oranges,  lemons,  and  cranberries,  Avere  ordered.  Fresh  air  and 
bathing,  with  vigorous  friction,  concluded  the  hygienic  treatment.  Under  this 
vigorous  treatment  the  child  developed  very  fast.  The  length  of  the  body  was 
58^/2  centimeters  at  the  end  of  the  first  month  of  this  treatment.  The  growth, 
therefore,  in  one  month  amounted  to  8  centimeters  or  3  '/s  inches.  The  obstinate 
constipation  was  imijroved.  and  the  bowels  became  regular.  The  teeth  have 
appeared  at  regular  intervals.  The  facial  expression  has  clianged.  The  child  now 
commences  to  walk,  as  also  to  talk,  she  says  "mamma"  and  '"papa."' 

The  fear  of  water  and  to  be  bathed  is  past.  She  no  longer  cries  when  she  sees 
water.  At  the  end  of  1  year,  the  length  of  her  body  is  85  centimeters  or  33  '/2 
inches,  so  that  she  has  grown  in  1  year  34^4  centimeters  or  13%  inches. 

The  child  is  still  taking  thyroid  and  is  progi'essing  favorably. 

Table  Xo.   100. — Length  and  Gruicth  of  Body. 


Age. 


Length  of  Body.  |  Gain  in  Growth  of  Body. 


2  yrs.  and  2  mos.  '  50i  centimeters  (19}!  inches)   | 

2  3'rs.  and  ;5  mos.  i  ~)%h  centimeters  (23y'5  inches)   i  1    mo.,    8  centimeters  (3|  inches) 

3  yrs.  and  3  mos.     85    centimeters  (33j   inches)   ;  13  mos.,  34^  centimeters  (130  inches) 

Case  II. — Rosie  IL,  born  January  1,  1902,  now  over  2  years  old,  was  first  seen 
by  me  when  she  was  eighteen  months  old. 

Family  Histori/. — Father  living,  is  somewhat  dyspeptic.  Has  no  specific  disease. 
The  mother  is  a  very  nei'AOUs  woman,  otherwise  in  good  health.  This  is  her  first 
child.  She  has  had  one  other  pregiiancy  of  eiglit  months  which  was  still-born, 
believed  to  have  been  an  asphyxia  neonatorum.     Xo  miscarriages.     Xo  lues. 

Child's  History. — She  was  breast-fed  for  seven  months,  later  she  received  e<iual 
parts  of  milk  and  water,  ^\'hen  first  seen  by  me  at  the  age  of  eighteen  months,  she 
was  still  fed  on  equal  ])ar1s  of  milk  and  water.  T"Tiere  has  always  been  severe 
constipation,  and  streaks  of  l)l()od  luue  frequently  been  seen  in  the  stool  from  severe 
tenesmus.  The  examination  of  tlie  child  a1  Unit  time  showed  coarse,  sjiarse  hair, 
and  a  very  rough  skin.  The  tongue  and  Ihe  lips  were  very  tliick.  The  tongue 
always  protruded  from  the  mouth;  breathing  was  diflicuH.  There  was  constant 
snoring,  and  the  moulh  was  always  open.  The  thorax  was  decidedly  rachitic;  there 
was  a  funnel-shaped  depression,  and  also  a  kyphosis  and  an  mnbilicated  hernia.  The 
child  could  neither  stand  nor  talk.  There  was  no  evidence  of  teething.  The  appetite 
was  poor.      The  temperature  was  subnormal,  98 'Vg°  in  the  rectum.      The  pulse  was 


764  DISEASES    OF    THE    DLLTLESS    GLANDS. 

100,  small,  and  feeble.  The  heart  sounds  muffled.  A  hsemic  munnur  was  plainly 
lieaid  at  the  apex  and  also  in  the  vessels  of  the  neck.  It  was  impossible  to  secure 
a  specimen  of  urine  for  examination.  A  drop  of  blood  was  examined  and  showed  a 
decreased  number  of  red  blood-corpuscles  and  a  marked  leucocytosis.  The  diagnosis 
made  was  sitonidic  cretuiism.  The  circulation  was  poor  and  there  was  a  slight 
(pdema  constantly  present.  The  feet  and  hands  were  frequently  cyanotic,  and  always 
felt  cold.  The  anterior  fontanel  was  widely  open.  Growth  was  stunted  as  the 
length  of  the  body  was  only  55  centimeters.  The  naked  weight  when  1  V2  years  old 
was  11  pounds  13  ounces.  \Mien  first  seen  by  me  there  was  neither  muscular  nor 
bony  development  whicli  could  be  considered  normal.  At  eighteen  months  the  child 
liad  liad  no  teeth.  At  twenty-two  months  tiie  first  tooth  appeared.  The  muscles  of 
tlie  body  were  limp  and  Ihibby.  Tlie  child  could  not  support  her  head  nor  was  there 
good  support  to  the  spinal  column.     The  patellar  reflexes  were  but  slightly  present. 

T)ratiiinit. — The  treatment  consisted  in  giving  fresh,  raw  milk  warmed  to  body 
temperature.  In  addition  to  the  milk,  steak  juice,  orange  juice,  potato  flour,  and 
the  usual  antiscorbutic  remedies  were  ordered.  Fresh  albumin,  using  the  raw  white 
of  egg,  and  vegetable  proteids,  such  as  pea  soup  and  lentil  soup,  were  very  well 
assimilated. 

The  iiiedicinal  treatment  consisted  of  two  drugs.  Thyroidine  was  given  in  doses 
of  V2  grain  three  times  a  day,  and  gradually  increased  until  3  grains  were  given  three 
times  a  day.  The  other  drug  was  Fowler's  solution  given  in  1  drop  doses,  increased 
to  3  drops  three  times  a  day.  It  is  now  about  six  montlis  since  the  treatment  was 
commenced.  The  child  has  grown  in  length  from  55  centimeters  to  69  centimeters 
and  the  weight  has  increased  from  11  pounds  13  ounces  to  17  pounds. 

Case  III. — Rosie  N.  was  fii"st  seen  by  me  on  June  28,  1902.  She  was  then 
seventeen  months  old. 

Family  History. — Fatlier  is  healthy.  No  family  history  of  tuberculosis,  syphilis, 
or  any  other  taint.  The  mother  is  in  good  health  and  has  never  had  any  serious 
illness  nor  miscarriage.  This  was  her  first  pregnancy.  The  mother's  condition  was 
good,  there  was  no  traumatism  nor  any  psychic  disturbance.  Tlie  infant  was  born 
without  the  aid  of  instruments.  It  was  a  perfectly  normal  delivery.  The  mother 
menstruated  while  nursing  the  infant. 

Permnal  History. — The  infant  was  nursed  about  sixteen  months.  Slie  did  not 
seem  to  thrive  since  she  was  three  montlis  old.  Severe  constipation  had  always 
existed,  and  was  present  when  I  first  saw  her.  She  could  neither  stand,  walk,  nor 
talk.  Backwardness  in  development  was  very^  apparent.  Spasmus  nutans  was 
present.  The  fontanel  Avas  widely  open.  Slie  sliowed  no  signs  of  intelligence.  The 
hair  was  coarse  and  straight.  The  extremities  were  short.  The  growth  stunted. 
She  presented  a  squatty  appearance.  Tlie  skin  was  rough,  thickened,  and  large 
eczematous  patches  covered  the  arms  and  legs.  The  child  was  sent  to  me  by  Dr. 
L.  Weiss,  who  had  her  under  his  care  for  the  relief  of  the  eczema.  The  lips  were 
thick.  The  tongue  was  thick  and  protnuling.  She  had  two  lower  incisors;  no 
other  evidence  of  dentition.  The  facial  expression  was  senile  and  corresponded  with 
that  of  a  typical  cretin.  She  was  restless  by  day  and  suflFered  with  insomnia  by 
night.  Tlie  urine  was  examined  and  contained  no  albumin  nor  sugar.  Slight  traces 
of  indican  were  seen,  microscopically  nothing  pathological.  The  blood  examination 
showed  four  million  six  hundred  and  twenty  thousand  (4. 020, 000)  red  blood-cor- 
puscles, and  seven  thousand  two  liundred  (7200)  white  cells. 

The  percentage  of  hremoglobin  taken  with  Gower's  instrument  was  about  40 
per  cent.  As  digestion  was  very  poor  I  decided  to  syphon  off  the  gastric  contents 
two  hours  after  a  meal  and  to  examine  the  same  chemically. 


CRETINISM. 


765 


Sporadic    Cretixism. 

Fig.  2.39.— C'liild.  Age  I 
year,  5  nioiitlis.  {Oi'ig- 
inal.) 

Fig.  240. — Same  child.     Ago 

2  year.s.       (Original.) 

Fig.  241.— Same  child.     Age 

3  year.s,  5  months.     (Orig 
inal.) 


I'lK.    S.i 


Fig.  2-10. 


Fig.  241. 


TOG 


DISEASES    OF    THE    DUCTEESS    GEANDS. 


Feediiit/. — The  feeding  was  barley  water.  About  5  eubic  centimeters  were 
syphoned  off,  whie)i  sliowed  tniees  of  peptones,  starch,  and  sugar:  HCl  was  absent 
Uy  CJunzberg's  test.  1  am  indebted  to  Air.  Charles  EaA\'all  for  iiis  assistanee  in  the 
eheniieal  analyses  of  the  gastric  contents,  made  a  number  of  times. 

E<]ual  part.s  of  milk  and  barley  \\ater  were  fed  every  few  hours.  Thyroid 
treatment  was  commenced;    '/j  grain  of  the  (lesiccate<l  powdered  thyroids  was  ordered 


Fig.  242. — Cretinism.    Age  7, '4  years. 
26%  inches.     Front  view. 


Height 


Fig.  243.— Cretinism.    Age  7}^  years.  Heiglit 
26>^  inches.    Back  view. 


tliree  times  a  day.  The  dose  was  gradually  increased  and  the  child  now  receives  3 
grains  three  times  a  day.     There  was  no  cardiac  disturbance  from  this  dose. 

I.fenion  juice,  orange  juice,  raw  albumin,  and  vegetable  soups  were  ordered. 
The  child's  condition  improveil.     The  specific  effect  of  the  thyroid  was  very  apparent. 

Ca.se  IV. — Gussie  S.,^  7  years  and  3  months  old  when  she  came  under  my  obser- 
vation. She  was  bom  January,  ESn7.  She  is  the  oldest  of  foui-  children.  The  other 
children  are  to  all  appearances  healthy,  as  are  also  the  parents. 


"I  regard  this  case  as  the  most  complete  type  of  cretinism  that  I  have  ever 
seen.  The  notes  Avere  kindly  furnished  by  Dr.  A.  E.  Isaacs,  in  M-hose  practice  the  case 
occurred. 


cri:tlms.\i. 


767 


FamUii  Uifttory. — Tlie  motlier  claims  to  have  had  a  severe  fright  during  her 
sixth  month  of  pregnanc-y,  and  attributed  the  child's  mental  deficiency  to  this  psyi-h- 
ical   disturbance.      There  is  no  historA-   of  any  condition   similar  to  this  child's   on 


Fig.  244.— Cretinism.    Same  case.    Age  S  years. 
Jleigtit  'A'i)4.  inches,  gain  6-'4  inches. 


Fig.  24.>. — Cretinism.    Same  case.     Age  8  years. 
Ileigln,  3;S':j  inches,  gain  B%  inches.     Back  view. 


either  side  of  the  family,  l^iicnts  are  natives  of  Russia.  They  are  13  years  in  this 
country,  and  do  not  know  of  any  such  disease  in  their  native  cotmtry.  The  parents 
are  not  related. 

Frcdiny. — The  child  was  breast-fed  for  about  two  years.  She  did  not  receive 
any  other  food  during  this  period.  When  the  child  was  thirteen  months  old  the 
mother's  menstruation  returned.  Tlic  mother  contintied  to  ntu-se  the  child  until  the 
end  of  the  second  year,  although  she  continued  to  menstruate  every  month. 

Nothing  unusual  was  noticed  about  this  child  until  the  end  of  her  first  year. 
She  cried  very-  little  and  slept  a  great  deal.  At  about  1  year  of  age  parents  noticed 
that   she  differed   from  other  children   of  the  same  age.      No  teeth  appeared.      She 


1i5H 


DISEASES    QF    THE    DlC  TLKSS    GT.ANDS. 


made  no  attempt  to  walk  or  stand.  >s'cver  laughed  or  smiled,  was  always  apathetic 
and  took  no  interest  in  her  sinroundings.  There  was  no  appreciable  growth  in 
heiglil  l'i(ni\  1  to  7  years.  'llie  same  dresses  always  fitted  her.  in  her  fifth  year 
she  was  for  a  period  of  six  iiioiitlis  very  cross  and  restless,  but  this  disappeared  as  it 
came,  without  any  known  cause. 


I  i^.  .-,1..— I  u.,i,L-iii.     .Siiiic  ( asi'.     .\gc    '.)  \iar 
Height  37%  inches,  gain  4'^  iiicl'.e-i.     Front  viiw. 


1  ig.  2J7.— <  rcliiiisni.    .Same  case.     Age  9  year.' 
Height  :M%  iiulies,  gain  4T^  inches.  Ba(  k  view. 


She  cut  her  incisor  teeth  at  .?  years  of  age  and  (he  rest  at  4  years.  She  has 
never  had  convulsions  or  any  other  sickness  except  measles  when  4  years  of  age. 
She  "began  to  stand  on  her  feet  with  assistance  Avhen  3  years  old.  She  did  not  speak 
a  word  until  5  years  old,  from  which  time  till  I  took  charge  of  her  she  could  say 
no  more  than  "papa"  and  "mamma." 

When  she  came  under  my  observation,  she  was  26  Vj  inches  high.     She  weighe<I 


CRET1^'LSM. 


769 


25 ''/a  pounds  and  was  quite  stout  in  proportion  to  her  height.  Her  head  was  large 
in  proportion  to  her  body.  The  lips  were  thick.  The  nose  flat  and  depressed  betweeji 
the  eyes.  The  neck  was  very  short.  No  sign  of  enlarged  tliyroid,  large  blue  eyes, 
teeth  in  fair  condition,  complexion  dark,  hair  dry  and  of  a  rusty  black  color. 


lleiglit  '.i9%  inches,  gaiii  2  inches.     Front  view. 


I  ii;.  -I'.L— I  retini^ra.     Sanic  cuse.     Agcllyears. 
Ilciglit  :;'.)).j  inches,  gain  2  inches.     Back  view. 


Hearing,  sight,  and  smell  apparently  good.  Voice  not  out  of  the  ordinary. 
The  extremities  were  short  and  thick,  lower  ones  were  bow-legged.  The  ends  of  the 
bones  were  large.  The  belly  was  large  and  its  prominence  exaggerated  by  a  decided 
anterior  curvature    of   the  spine.       Intelligence   was   almost    nil,   temperament   very 


770  DISEASES    OF    THE    DUCTLESS    GLANDS. 

irritable,  does  not  cry,  but  becomes  very  angi-y.  She  never  asks  for  food,  eats  little 
and  only  wliat  is  given  to  her.  The  bowels  were  constipated,  moving  only  once  in 
two  days.  Slie  never  asks  to  i)ass  stool  or  water.  Had  external  luemorrhoids,  which 
bled  occasionally.  When  awake  was  constantly  sitting.  Cannot  walk  alone  and 
only  a  few  steps  when  assisted.     She  slept  well.     Pulse  was  90  and  regular. 

Has  had  no  treatment  for  three  years.  Previous  to  this  time  parents  had  been 
all  over  with  her  and  tried  everything  suggested,  without  avail. 

On  January  2,'),  1897,  I  put  her  on  3  grains,  once  a  day,  of  desiccated  thyroids 
(Parke,  Davis  &  Co.).  On  February  18th  dose  was  increa.sed  to  4  grains  daily,  but 
after  a  week  the  dose  had  to  be  reiluced  to  2  grains,  as  the  pulse  rose  to  120  and  the 
chUd  became  irritable.  Otherwise,  some  improvement  was  already  noted  in  lier 
general  condition;  she  could  stand  better  and  moved  her  bowels  daily.  After  anotlier 
week  (March  6th)  the  dose  was  increasetl  again  to  3  grains  daily  and  was  continued 
so  till  I  saw  her  on  March  21st,  when  I  found  her  pulse  144,  strong  and  bounding. 
She  had  become  considerably  thinner,  having  lost  1  V2  pounds  in  weight  in  spite  of 
the  fact  that  she  had  gaineil  2  inches  in  height.  This  gave  her  a  much  more  natural 
appearance.  She  also  had  a  more  intelligent  facial  expression,  talked  more  and 
decidedly  better,  walked  a  short  distance  \\ithout  assistance,  and  ate  better. 

On  accoimt  of  the  accelerated  pulse  and  loss  of  flesh,  1  decreased  .the  thyroids 
again  to  2  grains  daily.  From  this  tjme  on  there  was  a  giadual  improvement  in  all 
the  symptoms.  By  the  middle  of  April  she  was  iimning  about  the  streets,  playing 
with  other  children,  and  asked  for  her  food.  In  May  she  began  to  tell  when  she 
wanted  to  move  her  bowels,  gradually  gained  in  intelligence,  spoke  more  and  articu- 
lated better.  The  dose  of  the  thyroids  was  gradually  increased  until  she  w^as  taking 
5  grains  daily  (July),  which  she  continued  for  more  than  a  year  and  a  half  without 
any  symptoms  of  intoxication. 

I  had  the  honor  of  presenting  her  before  the  Soeiety"^  in  1898  after  one  year's 
treatment,  when  she  had  gained  (5  V^  inches  in  height.  Tlie  privilege  was  accorded 
me  again  in  1899  when  she  had  gained  an  additional  4  V2  inches.  The  average  groAvth 
of  a  normal  child  of  her  age  is  less  than  2  inches  a  year.  She  had  f/aiiied  or'^r 
eleven  (11)  inelies  in  two  years. 

As  interesting  as  this  case  is  so  far.  tlic  most  significant  and  interesting  part  of 
it  comes  now.  I  lost  track  of  the  patient  in  .January,  1899,  and  she  took  no  medicine 
from  that  time  until  I  saw  her  again  in  December,  almost  a  year  later.  My  note- 
book records  the  fact  that  tliere  was  no  increase  in  height  and  that  her  genera! 
appearance  was  not  good.  Although  I  ordered  the  thyroid  extract  it  was  not  given 
again  until  I  saw  the  patient  one-half  year  later,  on  -June  1st,  1900,  and  again  there 
was  no  increase  in  height  or  improvement  in  general  condition.  The  patient's  next 
visit  was  in  February,  1901,  when  she  reported  that  5  gi-ains  of  the  thyroid  had  been 
given  daily  from  June  1st  to  December  24th.  Measurement  showed  a  gain  of  2  inches 
in  height  (39  V2)-  Her  general  appearance  was  much  better  and  she  had  been  going 
to  school  for  a  few  weeks. 

If  any  proof  be  necessary  as  to  the  efficacy  of  the  thyroid  principle  in  cretinism, 
or  as  to  the  thyroid  gland  and  its  secretion  being  essential  to  the  proper  physiological 
workings  of  the  human  body,  the  history  of  this  case  supplies  it.  Take  the  one 
s^Tnptom  of  stature.  From  1  to  7  years  of  age,  without  the  administration  of 
thyroids,  there  was  no  increase.  From  7  to  8  years,  with  thyroids,  there  was  a 
growth  of  6 "/,  inches.  Fiom  8  to  9  years,  also  Avith  thyroids,  there  was  a  growth  of 
4V4  inches.     From  9  to  10  years.  A^thout  any  thyroids,  there  was  no  growth.     From 


*  Eastern  Medical  Society,  New  York  City. 


CRETINISM.  771 

10  Vj  to  11  yearsj  with  thyroids  again,  Z  iiu-lies  were  gainetl.  All  otlier  manifesta- 
tions of  tliis  cretinic  condition  underwent  corresponding  iiuetuations  with  the  ad- 
ministration of  the  extract,  hut  changes  in  stature  being  the  most  evident,  serve 
best  to  illustrate  the  progi-ess  of  the  case. 

To  contrast  her  previous  with  her  present  condition  as  well  as  to  show  her 
appearance  during  the  period  of  lier  improvement  no  better  means  could  be  utilized 
than  the  accompanying  photos.  The  first  pair  was  taken  in  Februaiy,  1897,  the 
second  in  1898,  the  third  in  1899,  and  the  fourth  in  February,  1901. 

She  is  now  sufficiently  intelligent  to  go  to  school.  She  plays  as  a  child  should 
and  her  general  health  is  very  good.  She  has  yet  the  physical  marks  of  her  previous 
condition  in  tlie  peculiar  features,  the  short  neck,  and  the  spinal  curvature  with 
the  alxlominal  prominence,  though  they  have  all  improved,  especially  the  spine  and  the 
abdomen.  Her  height  is  about  12  inches  short  of  what  it  should  be  at  her  age,  II 
years,  but  if  tlie  rapid  rate  of  gi'owth  continues  she  will  gain  a  good  part  of  it. 

September,  1901. — Has  taken  little  medicine.      Height  about  the  same. 

April  27,  1902. — Has  taken  medicine  one  and  one-half  months  since  last  visit. 
Height,  41  V*  inches ;    goes  to  school. 

September  4,  1902.— Has  taken  5  grains  daily  since  April  27th.  Looking  and 
feeling  well.  Losing  flesh,  feels  cold  at  night,  hands  tremble  when  taking  things  to 
mouth  since  six  weeks.  Pulse,  188.  Height,  41  V2  inches.  Discontinued  thyroids 
three  weeks. 

I  saw  case  on  December  20,  1902.  No  thyroids  since  last  week.  Patient  is 
gaining  flesh,  shivering  (trembling)  stopped.  Pulse,  72.  Goes  to  school,  has 
mastered  her  figures  only  (is  almost  13  years  old).  Ordered  2  V2  grains  thyroid 
daily. 

When  last  seen,  April  20,  1904,  the  mother  stated  the  girl  had  been  going  to 
school  for  the  last  two  years.  Very  little  mental  progi'&ss  has  been  made  during  this 
time.  She  reads  an  elementary  primer  and  can  remember  figures.  Has  taken  thyroid 
but  four  months  out  of  the  last  sixteen  months.  Her  height  is  43  V4  inches.  She 
has  gained  in  the  last  sixteen  months  about  two  inches.     Her  pulse-rate  is  72. 

Prognosis  and  Course.- — Tlie  sooner  treatment  is  instituted  the  l)etter 
tlie  result.  When  this  condition  is  neglected,  children  become  worse  and 
worse  until  finally  they  are  beyond  medical  aid. 

It  must  be  borne  in  mind  that  thyroid  jnust  be  given  for  years  if  last- 
ing results  are  to  be  obtained.  Children  will  go  backward  at  once  if  we 
discontinue  our  treatment,  even  though  the  same  has  been  continued  for 
some  years.  An  interesting  study  is  the  continuous  growth  including  men- 
tal development  plainly  seen  in  the  ilhistrations  of  cases  in  this  chapter. 

Treatment. — The  most  important  part  of  the  treatment  consists  in 
administering  from  1  to  5  grains  of  the  dessiccated  extract  of  thyroid. 
This  replaces  the  active  principle  of  the  normal  thyroid  gland.  1  have 
used  with  very  good  success  thyroid  in,  from  Vo  to  2  grains  three  times  a 
day,  with  equally  good  result. 

Great  care  should  be  taken  to  watch  the  pulse-rate  while  giving  thy- 
roid. The  pulse  will  sometimes  increase  from  twenty  to  forty  beats  after 
the  administration  of  1  or  2  grains  of  thyroid.  The  moment  we  find  an 
exaggerated  pulse-rate,  it  will  be  necessary  to  reduce  the  dose  of  thyroid 


772  DISEASES  OF  THE  DUCTLESS  GLANDS. 

;it  Iciist  oiu'-liaif.     A  flabbv,  fat  child  will  at  once  lose  weight,  and  an  iiiipor- 
lant  feature  of  successful  treatment  is  an  increase  in  height. 

Thyroid  I inplduldtiou. —  Implantation  of  sheep's  or  lamb's  thyroid 
(heterogeneous),  or  from  the  human  being  (homothyroid),  has  l)een  advo- 
cated bv  some.  In  one  case  of  mine,  opei'ated  by  Dr.  Ilow^ard  Lilienthal, 
the  implantation  of  laml)'s  thyroid  was  tried.  Sevei-al  pieces  were  im- 
planted in  the  peritoneal  cavity.      Some  improvement  was  noted.  J 

^Ye  must  not,  however,  blindfold  ourselves  to  the  be.ief  that  when  we     , 
supply  the  missing  internal  secretion,  namely,  thyroid,  that  we  have  ful- 
filled all  indications. 

The  diet  must  be  regulated  and  the  child  given  a  large  portion  of  pro- 
teids — milk,  meat  or  meat  extracts,  fresh  beef  blood  or  roast  beef  juice, 
orange  juice,  fresh  eggs,  and  all  cereals  must  be  given  as  body  builders. 
Fresh  air  and  a  general  attention  to  the  hygienic  condition  of  the  child  are 
very  important.  Massage,  gymnastics,  and  exercise  should  not  be  over-  i 
looked. 

If  the  appetite  is  poor  1  to  2-minim  doses  of  the  tincture  of  nux  vomica 
will  do  good..    Butter  and  codliver-oil  are  valuable  adjuncts. 

Exophthalmic  Goiter  (Hyperthyrea,  Basedow's  Disease, 
Graves's  Disease). 

This  disease  has  occasionally  been  seen  in  children.  It  is  supposed  to 
be  due  to  a  hypersecretion  of  the  thyroid  gland.  Sachs  believes  that  hered- 
ity is  a  more  important  factor  than  excitement  or  fright.  Epileptic  and 
alcoholic  parents  certainly  predispose  to  this  condition  in  children. 

Symptoms  and  Diagnosis. — There  are  three  symptoms  of  importance 
which  should  be  noted  : — 

1.  The  enlargement  of  the  thyroid. 

2.  Palj)itation  of  the  heart  (tachycardia). 

3.  Protrusion  of  the  eyeballs  (exophthalmus). 

The  Ijlood  tension  is  increased,  hence  hemorrhages  from  the  nose, 
stomach,  or  intestines  are  (|uite  common.  Disturbances  of  vision  due  to  the 
(exophthalmus  are  never  described.  The  thyroid  enlargement  is  usually 
bilateral.'  Muscular  tremors  are  also  noted.  The  diagnosis  is  easily  made  by 
recognizing  the  symptoms  above  described.  There  is  a  ])hysiological  hyper- 
aemia  of  the  thyroid  which  is  entirely  different  from  goiter. 

Prognosis. — Cases  seen  by  me  have  all  assumed  a  chronic  tendency.  I 
have  never  known  death  to  occur  directly  from  this  condition.  When  death 
occurred  it  was  due  to  some  complication. 

Treatment. — Spartein  sulphate,  strophanthus,  digitalis  or  belladonna 
combined  with  iodide  of  sodium  may  be  tried.  The  galvanic  current  is 
strongly  advised  by  some  writers.      Eecently  x-ray  treatment  has  been 


DISEASES    OF    THE    THYMUS    GLAND.  773 

used  in  conjunction  with  the  above  mentioned  drugs.  The  danger  of 
x-ray  dermatitis  should  be  remembered  by  those  having  little  experience 
with  light  treatment. 

The  use  of  thyroid  has  been  suggested,  but  it  has  failed  to  do  good  in 
my  hands. 

Acute  Thyroiditis. 

Inflammatory  conditions  such  as  abscess  have  been  described  as  a  com- 
plication of  tbe  infectious  diseases.  The  migration  of  streptococci  or  other 
pyogenic  bacteria  may  give  rise  to  suppurative  inflammation.  The  treat- 
ment is  surgical. 

Abnormality  of  the  Thyroid. 

Syphilitic  gummata  and  tuberculosis  have  been  found  in  rare  instances. 
Malignant  disease  involving  the  thyroid  has  been  reported  among  infantile 
disorders. 

Diseases  of  the  Thymus  Gland. 

In  rare  instances  the  thymus  gland  may  persist  until  the  twentieth  year 
or  even  later  in  life.  \Yhen  such  a  condition  exists  mechanical  pressure  has 
caused  dyspnoea  of  a  serious  nature.  Asthma  has  l)een  reported  by  some 
clinicians  in  which  an  enlarged  thymus  was  found,  hence  the  term  "thymic 
asthma."  Sudden  death  lias  occasionally  been  caused  by  an  enlarged  thy- 
mus. This  has  been  especially  noted  in  children  with  rickets.  Abscesses 
have  been  reported  in  the  thymus  by  Dubois.  Syphilis  and  tuberculosis  have 
rarely  been  found. 

Keicli  says :  '"'i'he  absolute  dullness  of  the  thymus,  as  determined  by 
light  percussion,  is  irregularly  triangular  in  outline,  the  base  being  made 
by  the  outline  connecting  the  two  sterno-clavicular  articulations,  the  blunt 
apex  situated  at  the  level  of  the  second  rib  or  slightly  below  it,  and  the 
sides  a  little  beyond  the  edges  of  the  sternum.  The  larger  half  of  this 
triangle  of  dullness  usually  falls  to  the  left  side.  When  the  limits  of  dull- 
ness, as  given  above,  vary  l)y  one  or  more  centimeters,  or  obscure  the  pul- 
monary resonance  between  the  upper  line  of  cardiac  dullness  and  the  lower 
lateral  limits  of  thymus  dullness,  an  enlargement  of  the  thymus  is  probable. 
The  thymus  dullness  is  jiresent  until  the  eiul  of  tlie  fifth  year,  after  which 
it  is  inconstant." 

Diagnosis. — The  diagnosis  of  diseases  of  the  thymus  gland  is  frequently 
impossible.  An  infiltration  or  swelling  of  the  area  surrounded  l)y  the  tiiy- 
mus  gives  rise  to  symptoms  of  dyspnoea,  from  pressure  upon  tlie  pneumo- 
gastric  nerve.  The  same  symptoms  are  also  found  when  the  thymus  itself 
is   enlarged.     When   the   lymph   glands   in    tiie   anterior   mediastinum   are 


774  DISEASES    OF    THE    DUCTLESS    GLANDS. 

swollen,  dullness  on  percussion  is  rare  unless  there  is  a  cheesy  infiltration 
of  the  lymph  glands,  according  to  Keich. 

Treatment. — Symptomatic  treatment  only  should  be  instituted.  Tlie 
iodide  of  sodium  in  very  large  doses  may  be  tried. 

Diseases  of  the  Aduenal  Glands. 

Pathologists  have  frequently  described  haemorrhages  into  the  adrenal 
glands  in  the  new-born  infant.  Diseases  per  se,  excepting  cancer,  have  not 
been  described.  There  is  still  considerable  to  be  learned  concerning  the 
physiology  of  these  glands. 

Addison's  Disease. 

This  rare  condition  is  occasionally  described.  Literature  records  about 
twenty  cases  in  all. 

Symptoms. — The  symptoms  of  the  disease  consist  of  a  deep  yellowish 
or  bronzed  pigmentation  of  the  skin.  It  is  found  on  the  exposed  parts  of 
tlie  body,  such  as  the  hands  and  head.  The  mucous  membranes  of  the  mouth 
and  vagina  are  also  pigmented.  White  areas  of  skin  are  scattered  over  the 
body.  Vomiting,  diarrhoea,  and  nervous  symptoms  are  noted.  Anaemia  is 
usually  very  marked. 

Diagnosis. — In  the  diagnosis  of  this  condition  it  is  necesary  to  exclude 
pigmentation  of  the  skin  due  to  metallic  poisons,  such  as  argyria,  from  the 
internal  administration  of  nitrate  of  silver.  Arsenic  and  lead  have  been 
reported  as  causative  factors  of  bronzed  skin. 

Prognosis. — While  most  authors  report  the  outcome  as  fatal,  some  few 
recoveries  have  been  noted.  In  a  case  seen  by  me  recovery  took  place  after 
several  years  of  treatment. 

Treatment. — We  have  no  specific  treatment  for  this  condition.  Some 
authors  advise  the  administration  of  the  raw  or  cooked  adrenal  glands  of 
the  sheep.  The  dry  extract  in  tablet  form  has  been  isolated  and  1-grain 
doses  of  this  extract  may  be  given  three  times  a  day.  When  the  gland 
itself  is  used,  one-half  to  one  gland  may  be  given  in  twenty-four  hours. 

The  value  of  hygienic  and  dietetic  measures  I  regard  as  more  impor- 
tant than  medication. 


PART  IX. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 


CHAPTER  I. 
FONTANEL. 


The  posterior  fontanel  is  usually  closed  at  the  end  of  the  second  month. 
The  anterior  fontanel  normally  closes  between  the  sixteenth  and  twentieth 
months.  If  the  fontanel  is  open  at  the  end  of  the  second  year,  then  rickets 
or  other  abnormality  may  be  considered.  A  fullness  of  the  anterior  fontanel 
and  bulging  of  the  same  at  the  end  of  the  second  year  is  pathological.  (See 
chapter  on  "Hydrocephalus.")  Premature  closure  of  the  fontanel  fre- 
quently occurs  in  microcephalus  and  also  in  congenital  idiocy.  This  prema- 
ture closing  interferes  with  the  proper  growth  and  development  of  the  brain. 

Shape  of  the  Head. — Peculiar  shapes  of  the  head  are  met  with  unde' 
perfectly  normal  conditions.  An  interesting  study  is  the  series  of  outline 
sketches  of  the  head  which  show  the  modifications  in  form  produced  by 
labor  and  also  the  normal  sketches  of  .the  head. 

Circumference. — The  average  circumference  of  the  head  at  birth  in  446 
full-term  infants  taken  in  about  equal  numbers  from  the  Sloane  Maternity 
Hospital  and  Xew  York  Infant  Asylum,  quoted  by  Holt,  was  as  follows: — 

Average  circumference  of  the  head,  231  males..    13.90  inches   (35.5  centimeters) 

Average  circumference  of  the  head,  251  females    13.52  inches   (34.5  centimeters) 

Total 446  infants.  13.71  inclies   (35.0   centimeters) 

Auscultation  of  the  Anterior  Fontanel. — A  bruit  is  occasionally  heard 
over  the  anterior  fontanel.  (Plates  23,  23.)  It  is  a  blowing  sound 
similar  to  that  heard  in  the  vessels  of  the  neck  during  anaemia  or  in  chlorotic 
girls.     I  have  described  this  condition  in  the  chapter  on  "Eachitis/' 

Percussion  of  the  Skull. 

]\IacEwen,  in  his  treatise  upon  the  pyogenic  infective  diseases  of  the 
brain  and  spinal  cord,  says:  "When  the  lateral  ventricles  are  distended  with 
serous  fluid,  as  would  be  occasioned  by  cerel)ral  tumors  pressing  on  the 
fourth  ventricle,  or  by  occlusion  of  the  veins  of  Galen  or  otherwise,  the  per- 
cussion note  is  markedly  altered,  the  resonance  being  greatlv   increased. 

(775) 


776  DISEASES    OF    THE    ^'EllVOLS    SYSTEM. 

Outline  Sketches  of  the  Head,  Showing  the  Various  Diameters. 


Fig.  250.— Sagittal  Section  of 
Normal  Head  of  Seven  and  One-half 
Months'  Foetus,  Half  Natural  Size. 
(After  Ballantyue. ) 


Fig.  252 — Sagittal  Section  of  Normal 
Head,  Half  Natural  Size.   ( After  Budin, ) 


Fig.  251. — Normal  Head  as  Seen 
from  Above,  Half  Natural  Size.  (After 
Budin.) 


Fig.  253.— Sagittal  Section  of  Head  Im- 
mediately After  Normal,  Easy  Labor, 
Half  Natural  Size.     (After  Ballantyne. ) 


Besides  tlie  incroasod  resonance,  there  is  an  important  feature  wliicli  may  be 
flemonstrated  :  The  percussion  elicited  at  a  given  spot  on  the  cranium,  sucii 
as  the  pterion.  varies  according  to  the  position  of  the  liead.  AVhile  the  per- 
son sits  with  the  liead  upriglit,  the  most  resonant  note  is  brought  out  by 
percussion  toward  tlie  basal  level  of  the  frontal  bones  and  the  squamous 


OUTLINE  SKETCHES  OF  THE  HEAD. 


77 


Outline  Sketches  of  Head  of  Infant,  Showing  the  Modifications  in   Fobm 
Produced  by  Labor,  etc. 


Fig.  251.— Sagittal  Sec- 
tion of  Head  Immediately 
After  Labor  (O.  D.  P. 
Position).  ( After  Ballan- 
tyne. ) 


Fig.  255.— Sagittal  Sec- 
tion of  Head  Immediately 
After  Labor,  Half  Natural 
Size.  O.  D.  P.  Position. 
(After  Bud  in.) 


Fig.  256. — Sagittal  Section 
of  Head  of  Infant  Six  Days 
Old,  Half  Natural  Size. 
fAfter  Ballantyne. ) 


778  DISEASES    OF    THE    NERVOUS    SYSTEM. 

portion  of  the  parietal.  If  the  patient  hangs  his  head  to  one  side,  so  that 
one  parietal  is  placed  fairly  below  the  other,  the  greater  resonance  is  found 
on  percussion  of  the  lower  parietal.  Eeverse  the  position  and  the  same  note 
is  elicited  on  the  opposite  side  of  the  head,  which  is  now  the  lower,  the 
greater  resonance  being  found  at  that  part  of  tlie  skull  nearest  the  lateral 
ventricles,  and  which  for  the  time  is  at  the  lowest  level. 

''These  observations  tend  to  indicate  that  the  quality  of  this  note  is 
not  dependent  on  the  mere  density  of  the  diameter  of  the  cranium,  but  to 
a  large  extent  upon  the  consistence  or  arrangement  of  the  intercranial  con- 
tents relatively  to  the  osseous  walls.  .  .  .  The  exact  mechanical  quality 
of  the  note  is  difficult  to  describe,  but,  when  heard,  it  conveys  the  idea  of 
hoUowness.  One  such  case,  in  which  the  above  phenomena  were  clearly 
marked,  was  observed  to  a  conclusion.  The  percussion  note  was  not  so  clear 
at  first  as  it  ultimately  became,  the  resonance  increasing  as  the  disease 
advanced. 

"In  tumors  of  the  cerebellum  it  is  an  aid  to  diagnosis,  and  when  present 
with  abscess  it  points  to  an  involvement  of  the  cerebral  fossa." 

The  Brain.^ 

In  the  new-born  the  dura  mater  is  closely  adherent  to  the  skull,  so  that 
extravasations  between  the  dura  mater  and  the  skull  are  unknoM^n. 

Fluid  in  the  Subarachnoid  Space. — In  infancy  and  childhood  more 
fluid  is  found  in  this  space  than  in  adult  life.  McClellan  believes  that 
"hydrocephalus  due  to  an  excessive  amount  of  fluids  in  the  ventricles  of  the 
brain  may  be  caused  by  the  closure  of  a  small  opening  in  the  pia  mater 
which  is  found  at  the  inferior  boundary  of  the  fourth  ventricle  known  as 
the  foramen  Magendie.' 

Blood-vessels  of  the  pia  mater  are  so  delicate  that  blood  pr.essure,  trau- 
matism, etc.,  may  cause  hemorrhage  into  the  subarachnoid  space,  resulting 
in  monoplegia,  ha^miplegia,  or  diplegia. 

Growth  and  Development  of  the  Brain.— From  birth  until  the  seventh 
year  is  reached  the  brain  grows  very  rapidly;  after  the  seventh  year  the 
growth  is  slow. 

Weight  of  the  Brain. — The  weight  of  the  brain  of  the  new-born  infant 
is  one-third  that  of  the  adult.  In  male  and  female  children  it  is  approxi- 
mately the  same  at  birth,  although  later  on  the  male  brain  grows  more 
rapidly  than  the  female.  When  a  child  is  between  7  and  8  3'ears  of  age, 
the  brain  reaches  the  adult  size  and  weight.  There  is  from  this  time  on  a 
slight  increase  in  the  weight  up  to  the  twenty-fifth  year. 

Vierordt  states  that  the  increase  of  the  brain  after  the  seventh  year  is 


'  The  development  of  the  senses  is  described  in  Part  T,  eliapter  on  the  "New-born 
Infant." 


PLATE    XXIII 


Front   ^'if■\v   of   tlii^   F<i't;il    Skull,    sliowinti'   the   anterior    fontanelle    and    the 
coronal    and    frontal    sutures.       ((Jrandin    &.    Jarniaii.) 


PLATE  XXIV 


Top    ^'i('\v    of    the    F(i'tal    Skull,    showing   the    anterior    fontanelle    and    the 
frontal,  coronal,  and  sagittal  sutvires.      (Grandin  &  Jarman.) 


PLATE  XXV 


Posterior  View  of  the  Foetal  Skull,  showing  the  posterior  fontanelle  and  the 
lambdoidal  and  sagittal  sutures.      (Grandin  &  Jarman.) 


REFLEXES.  779 

due  to  an  increase  in  the  thickness  of  the  cortex  and  in  the  size  of  the 
cortical  constituents. 

Difference  Between  Infantile  and  Adult  Brain. — The  fissure  of  Sylvius 
in  its  relation  to  the  spherio-parietal  and  squamous  sutures  occupies  a 
higher  position  in  childhood  than  in  later  life.  Symington  and  McClellan, 
in  studying  frozen  sections  of  the  brain  of  children  under  7  years  of  age, 
found  the  Sylvian  fissure  above  the  squamous  suture  and  covered  by  the 
parietal  bone. 

Fissure  of  Eolando. — The  position  is  the  same  in  the  infant  as  in  the 
adult. 

The  Cerebellum. — This  is  much  smaller  in  the  child  than  in  the  adult 
in  comparison  with  the  cerel^rum. 

The  convolutions  of  the  brain  are  more  shallow  in  the  infant  than  in 
the  adult.  The  depressions  or  sulci  between  the  convolutions  are  not  so 
deep  in  the  infant  as  in  later  life.  The  special  centers  of  the  brain  are  not 
fully  developed  iu  the  infant  (Taylor  and  Wells). 

Reflexes. 

Excess  of  Beflex  Action. — In  acute  mania,  in  cercbritis,  and  in  acute 
meningitis  we  have  excessive  reflex  action.  In  chronic  ha?miplegia  an  in- 
crease of  the  reflexes  associated  with  ankle  clonus  is  found  on  the  aifected 
side.  In  hydrophobia,  transverse  myelitis,  insular  sclerosis,  and  in  tetanus 
we  have  an  exaggeration  of  superficial  and  deep  reflexes.  Attention  is 
directed  to  the  chapters  on  "Tubercular  Meningitis"  and  "Epidemic  Cerebro- 
spinal Meningitis"  for  clinical  illustrations  of  the  reflexes. 

Diminution  of  Beflex  Actio?i. — The  reflexes  axe  lessened  and  sometimes 
absent  in  melancholia.  Extreme  pressure  in  the  cranial  cavity  or  in  the 
spinal  canal  will  reduce  the  reflex  act.  Whenever  a  degeneration  of  mus- 
cles or  nerves  takes  place,  such  as  in  diphtheria  or  other  specific  diseases,  the 
reflexes  will  be  lessened.  The  reflex  is  reduced  or  wanting  in  acute  anterior 
poliomyelitis. 

Bahinsl'i  Befle.r. — In  the  new-born  Ijaby  this  reflex  has  frequently  been 
noted  under  normal  conditions.  Instead  of  normal  flexion  of  the  toes, 
wliich  is  accom])lishod  by  irritation  of  the  soles  of  the  feet,  we  have  in  dis- 
ease a  hypere.rtcnsion,  of  the  great  toe.  This  symptom  is  regarded  as 
pathognomonic  by  f^ome  authors.  I  have  frcfjuently  found  this  symptom 
present  in  tuberculous  meningitis,  and  regarded  it  as  a  valuable  diagnostic 
aid.      (See  clinical  case,  art'cle  on   "Tubercular  "Afeningitis.") 

Beaclinn  of  Def/enprntion. — "In  lieallh  a  faradic  currcnl  of  sufficient 
strength  ap])licd  t<>  the  nerre  produces  a  continuous  contraction  of  the  mus- 
cle; the  galvanic,  a  niomentnry  coutrnction  wlicn  th(>  current  is  made  and 
broken  onlv.     When  the  nerve  is  diseased   a  stronger   faradic  or  galvanic 


780  DISEASES    OF    THE    NERVOUS    SYSTEM. 

curreut  is  needed  to  produce  coiitraetioD,  until  finally,  when  degeneration 
has  taken  place,  no  current  which  can  be  used  produces  any  contraction. 
In  health  either  current  applied  to  the  muscle  produces  contraction;  the 
response  both  to  the  <ialvanic  current  and  to  the  I'aradic  is  quick,  being  in 
both  instances  due  to  stinnilation  of  the  nerve-endings.  With  lesion  of  the 
nerve  and  consequent  degeneration  of  the  nerve-endings,  the  faradic  cur- 
rent ])roduces  no  contraction,  but  since  the  galvanic  current  is  capable  also 
of  stiniidating  the  muscle  fibers  themselves,  a  contraction  follows  appli- 
cation, though  more  slowly  than  when  the  nerve-endings  are  healthy.  After 
the  degeneration  has  progressed  to  a  certain  stage,  which  is  reached  the 
earlier  the  more  severe  the  case,  this  response  of  the  muscle  fibers  to  the 
galvanic  current  l)ecomes  more  ready  than  in  health.  •  To  this  quantitative 
change  is  added  a  qualitative  change.  In  health  the  weakest  galvanic  cur- 
rent which  causes  contraction  of  the  muscle  does  so  when  the  current  is 
made  with  the  negative  pole  on  the  nniscle  (kathode  closure  contraction, 
K.  C.  C).  When  the  nervous  mechanism  has  degenerated  a  contraction 
may  occur  with  as  weak  or  with  a  weaker  current  when  the  positive  pole  is 
on  the  muscle  (anode  closure  contraction,  A.  €.  C),  and  contractions  may 
occur  also  with  the  same  current  when  it  is  broken  (anode  opening  contrac- 
tion, A.  0.  ('.,  and  kathode  opening  contraction,  K.  0.  C.^).  To  this 
altered  qualitative  and  quantitative  reaction  of  nerve  and  muscle  to  the 
electric  currents  the  term  "reaction  of  degeneration"  is  applied.  It  is  not 
always  as  definitely  nuirked  as  is  above  described.  When  the  damage  to 
the  nerve  is  sliglit,  the  irritability  of  the  nerve  to  both  currents  may  be 
retained,  and  the  only  evidence  of  the  existence  of  a  reaction  of  degenera- 
tion is  increased  muscular  irritability  to  the  galvanic  current,  with  some 
change  also  in  the  order  of  contraction  to  the  poles  (qualitative  change). 
On  the  other  hand,  in  very  chronic  changes  the  loss  of  irritability  proceeds 
pari  passu  in  nerve  and  muscle,  and  the  reaction  of  degeneration  is  not  to 
be  observed. 

"With  the  regeneration  of  the  nerve,  recovery  of  function  takes  place, 
the  rate  of  recovery  depending  mainly  on  the  severity  of  the  lesion.  Vol- 
untary power  is  first  regained,  then  the  galvanic  reactions  become  normal, 
and  lastly,  the  faradic. 

"Anesthesia,  which  is  the  eventful  result  of  degeneration  of  a  sensory 
nerve,  may  be  preceded  by  a  condition  of  hyperjestliesia.  The  anaesthesia  is 
often  incomplete,  especially  in  the  hands  and  face;  in  a  mixed  nerve  a 
lesion,  capable  of  producing  paralysis  of  motion,  may  be  accompanied  by 
little  loss  of  sensation.  M'rophic  changes  seem  seldom  to  occur  in  children 
as  an  accompaniment  of  Icsioiis  of  sensory  nerves.'' 


'The  iionnal   onlor   is:       K.C.C.,  A.C.C.,   A.O.C.,  K.O.C. 


1 


CHAPTER  II. 

CONVULSIONS  (ECLAMPSIA). 

CoxvuLsioxs  occur  mostly  in  infancy.  After  the  seventh  year  of  life 
they  are  very  rare.  The  brain  grows  more  during  the  first  year  than  in  all 
later  life.  This  rapidity  of  growth  is  in  itself,  according  to  some  writers, 
an  important  predisposing  cause  of  functional  derangement. 

Etiology. — Tlie  Exciting  Causes. — The  predisposing  causes  may  be 
grouped  under  the  name  of  "central."     They  are : — 

1.  Diseases  having  a  high  temperature. 

2.  Diseases  accompanied  by  vascular  stasis. 

3.  Diseases  characterized  by  anemia  and  exhaustion. 

4.  Toxic  causes. 

5.  Organic  central  lesions. 

6.  Functional  disturbances  of  the  brain,  such  as  epilepsy. 

Of  all  the  manifold  predisposing  causes  of  convulsions  in  young  chil- 
dren, the  most  important  one  is  the  natural  instability  of  the  nervous  cen- 
ters, characteristic  of  early  life,  and  associated  with  the  non-development  of 
voluntary  centers  of  the  cortex ;  hence  it  is  that  age  is  a  most  important 
factor  in  the  etiology  of  convulsions;  and  under  2  j^ears  is  recognized  as 
by  far  the  most  susceptible  period.  Statistics  show  that  over  60  per  cent. 
of  deaths  from  convulsions,  up  to  20  years,  occur  in  infants  under  1  year 
of  age.  Convulsions  are  not  only  more  common  in  infancy,  but  much 
more  fatal  than  later  in  life,  and  for  reasons  that  are  very  ap})arent.  It 
has  been  stated  ])y  some  good  observers  that  males  seem  to  be  more  suscep- 
tible than  females ;  statistics  seem  to  justify  this  conclusion,  but  it  has 
been  suggested  by  others  that  inasmuch  as  more  males  than  females  are 
born  each  year,  the  larger  number  of  deaths  in  males  may  thus  be  recon- 
ciled, for  surely  it  would  be  contrary  to  reasonable  expectation,  as  females 
are  more  delicately  organized,  while  the  exciting  causes  are  ])rol)ably  about 
equal. 

Tlie  Feripherdl  Causes. — The  ])eripheral  causes  are  rachitis;  gastric 
disturbances,  such  as  acute  catarrhal  gastritis;  intcstinnl  worms;  foreign 
bodies  in  the  ear  and  nose,  causing  reflex  convulsions;  scalds  and  burns, 
and  mental  disturbances,  such  as  fright,  will  induce  convulsions.  Lewis 
says:  "Convulsions  are  in  all  probability  due  to  an  exaltation  of  the  lower 
nerve-centers;  or  more  fre(|uently,  to  a  sus])ension  of  the  inliibitory  power 
of  the  liiyher  cerebral  centers" — or  both  of  these  conditions  nuiv  exist  at 

(781) 


782  DISEASE.S    UF    THE    NERVOLS    SYSTEM. 

the  same  time — and  further,  "It  remains  to  be  said  that  we  are  still  very 
much  in  the  dark  as  to  the  iiuniediate  processes  producing  convulsions."' 

"Infants  lia\e  their  ner\()us  system  in  process  ot  rapid  development — 
only  the  component  but  undill'erentiated  })arts  of  which  are  in  great  activity, 
ready  to  receive  and  re-energize  limitless  new  impressions."  At  birth,  the 
lower  centers  only  are  develo])ed,  and  control  is  limited  until  the  higher 
centers  become  competent  to  exert  inhibition;  hence  in  the  earlier  months  of 
life  convulsions  are  common,  and  less  so  after  two  years. 

Improper  feeding  may  be  looked  upon  as  the  most  frequent  cause  of 
convulsions.  A  child  that  is  improperly  fed  and  suffers  M-ith  a  subacute  or 
chronic  form  of  dyspepsia,  suffers  with  a  deficient  structure.  Such  struc- 
tural weakness  resulting  in  rachitis,  is  a  cause  for  that  most  common  form 
of  spasm  known  as  laryngeal  spasm  and  tetany.  Toxaemic  conditions  re- 
sulting from  bacterial  infection  are  a  most  frequent  cause  of  convulsion. 

Pathology. — The  development  of  the  nervous  system  is  not  complete 
at  birth.  Very  little  light  is  shed  upon  convulsions  by  post-mortem  finding?^. 
Usually  after  death  from  convulsions  there  is  an  effusion  or  hasmorrhage 
found  or  there  is  a  venous  stasis  in  the  brain.  When  death  occurs  froui 
laryngospasm  it  results  from  suffocation.  The  condition  of  the  brain  iu 
the  beginning  of  an  attack  of  convulsion  is  one  of  anannia.  This  is  shortly 
followed  by  a  nervous  hyperaemia.  The  brain  and  meninges  are  usually 
found  intensely  congested  and  engorged.  fSometimes  punctate  haemorrhages 
can  be  found.  The  lungs  are  also  deeply  congested  and  the  right  heart  is 
generally  distended  with  dark  clots  (Holt). 

Symptoms. — There  is  usually  a  loss  of  consciousness.  Tke  onset  is 
sudden.  A  child  may  appear  perfectly  well  up  to  the  time  of  its  convulsion 
and  then  suddenly  the  arms  and  legs  become  stiff,  the  eyes  fixed  and  staring 
or  rolled  up  under  the  lids.  Eespiration  is  usually  arrested,  the  head  is 
retracted;  finally  the  whole  body  becomes  rigid. 

The  above  named  symptoms  belong  to  tJie  ionic  stage.  It  is  usually 
followed  by  clonic  convulsions  more  or  less  severe  and  prolonged,  affecting 
the  upper  and  lower  limbs,  the  face  and  eyes. 

Sometimes  the  tonic  and  clonic  convulsions  are  few  and  the  whole 
spasm  may  last  less  than  a  minute.  Some  children  show  no  sign  of  illness 
after  the  attack  is  over,  and  appear  perfectly  normal.  The  attack  may  recur 
at  short  intervals.  The  child  may  then  become  comatose  and  die  before 
proper  treatment  can  be  instituted.  It  is  important  to  examine  the  urine. 
The  possibility  of  a  nephritis  should  not  be  overlooked. 

Diagnosis. — It  is  usually  very  simple  to  differentiate  from  epilepsy. 
which  is  most  frequent  after  the  third  year. 

Convulsions  usually  are  the  first  symptoms  of  the  invasion  of  an  acute 
disease.  Scarlet  fever,  pneumonia,  malaria,  gastritis,  and  meningitis  may 
be  ushered  in  with  convulsions.    Measles  is  sometimes  preceded  by  convul- 


COX^T•LSIOXS.  783 

sions.  Pertussis  in  wliicli  there  is  cerebral  congestion  may  cause  convul- 
sions. Bronchitis,  nienibraninis  laryngitis,  and  laryugisnuis  stridulus  arc 
sometimes  preceded  l)y  convulsions.  Do  not  suspect  teething  or  worms  as 
a  cause  of  convulsions  until  all  other  causes  have  been  eliminated. 

Treatment. — The  treatment  of  convulsions  consists  of  controlling  the 
spasm.  Inhalations  of  chloroform  or  suli)huric  ether  should  be  cautiously 
used,  regardless  of  the  age  of  the  infant,  until  convulsions  cease. 

Chloral  hydrate  and  bromide  of  sodium,  with  some  starch  water,  should 
l)e  injected  into  the  rectum;  5  grains  each  of  chloral  and  bromide  with  a 
tablespoonful  of  starch  water  should  be  used  and  repeated  every  hour  until 
the  spasms  are  controlled.  Leeching  by  tlie  application  of  one  or  two 
leeches  behind  the  ears  is  valuable  to  relieve  cerebral  congestion.  We  can 
also  drain  blood  from  the  frontal  sinus  l)y  the  application  of  one  or  two 
leeches  at  the  alas  nasi.  A  mustard  foot-bath  should  likewise  be  used  until 
hyper^emia  of  the  skin  is  produced.  While  the  feet  are  suspended  in 
mustard  water  an  ice-bag  or  a  cold  cloth  should  be  applied  to  the  head. 

A  child,  4  year.-i  old,  was  suddenly  seized  with  convulsions,  clonic  and  tonic 
spasms  involving  the  face,  arms,  and  legs.  From  the  history  I  learned  that  the 
child  had  overloaded  its  stomach,  was  very  feverish,  and  thirsty.  A  mustard  foot- 
hath  Mas  ordered  and  a  rectal  injection  of: — • 

I^   Sodium    bromide     10  grains 

Chloral    hydrate   5  grains 

was  injected  into  the  rectum  with  two  tablespoonfuls  of  thin  starch  water. 

One  or  two   inhalations  of  chloroform  were  given   to   relieve  the   convulsions. 

The  diagnosis  of  acute  catarrhal  gastritis  was  made  and  the  convulsions 
attributed  to  a  general  toxiemia.  \Yhen  the  convulsions  ceased  the  stomach  was 
washed  with  two  quarts  of  warm  water  to  which  two  tablespoonfuls  of  salt  had  been 
added.     Food  was  disfontiiiucd  and  an  interval  dose  of:  — 

FJ   Sodium    bromide     5  grains 

Chloral  hydrate 2  grains 

was  given  every  hour  luitil  the  child  was  in  a  deep  sleep.  Twelve  hours  after  the 
convulsions  first  began,  thin  soup  and  broth  were  ordered.  The  child  was  well  in 
two  days. 

To  control  convulsions  : — 

R   Sodii  bromidi   5  grains 

Chloral    hydrate     5  grains 

Starch    water     : 1   tablespoonful 

Mix  thoroughly  and  inject,  if  possible,  into  the  colon,  tlirough  a  small  rubber 
catheter.     Repeat  every  hour  until  convulsions  cease. 

Lumbar  jiiniddic.  the  tccjniitjue  of  which  I  describe  elsewhere,  is  one 
of  our  most  valualde  tliorapcutic  measures.  By  withdrawing  30  to  .')0  cubic 
centimeters  of  cerebrospinal  fluid,  T  have  seen  niarked  benefit  therefrom. 
The  intracranial  pressure  which  was  relieved  by  this  procedure,  lessened  the 


784  DISEASES  OF  Till']  XKllVOUS  SYSTE:\r. 

irritability  of  llie  cliiltl  aiul  inoiuotcd  slet'i).  In  a  ease  of  auto-inlnxieatioii 
due  to  gastric  iVver.  with  a  temperature  ol'  Jo,")"  F.  and  owr,  in  a  ehild 
about  (Mgiileen  nmntlis  old  snllVi^inn'  willi  coiilinucd  convulsions,  tlu'  follnw- 
ing  oi'dci'  1)1'  li'eatment  \\'as  cai'ricd  nut:  I'^irst,  a  colonic  llusliing  to  cni|tty 
the  bowel;  second,  a  tc}tid  pack  o\cr  the  thorax;  thii'd,  a  lumbar  punctui'c, 
withdrawing  about  '2~>  cubic  centimeters  of  colorless  eei'ebros])inal  lluid  ; 
fourth,  a  diet  of  whey,  and  plenty  of  water  was  followed  by  an  amelioration 
of  all  the  symptoms. 

11  i:\i)Aciii;s. 

Various  forms  of  headache  are  eneountei'ed  in  children.  As  a  rule, 
very  little  reliance  can  be  placed  on  headaches  complained  of  l)y  young 
children.  IMiere  are  fonr  kinds  of  headaches  which  are  most  fi'efpiently 
seen  in  older  children: — 

1.  licflex  headaclR\ 

2.  Headache  due  to  general  systemic  cause. 

3.  Headache  of  local  origin. 

4.  Headache  due  to  l)rain  lesions. 

Beffc.v  Hcdilachc. — In  chlorotic  girls  or  in  anaemic  children  headache 
is  a  common  sym))tom.  During  menstrual  disorders  girls  will  usually  com- 
jilain  of  headaches. 

Hundreds  of  cases  of  headache  due  to  eye  strain  have  been  seen  by 
me  in  school  children.  These  children  complain  of  headache  during  and 
after  school  hours.  4'he  headache  disapjiears  during  the  night  and  the 
children  never  comi)lain  of  headache  in  the  morning.  j\Iost  of  these  cases 
have  been  referred  by  me  to  an  oculist,  who  as  a  rule  finds  astigmatism. 
The  treatment  consists  in   relieving  the  eye  strain  Ijy  wearing  eyeglasss. 

Ileadarhe  Duo  to  General  Si/stemic  Causes. — Headache  due  to  auto- 
intoxication resulting  from  imjiacted  faeces  is  fre(|uently  encountered. 
Eheumatic  children  ami  children  of  gouty  parents  frecpiently  complain  of 
headaches.  Such  headaches  are  frecpu'ntly  -found  in  litba-mia.  Th?  gen- 
eral constitutional  treatment  consists  of  a  diet  of  vegetables,  and  fruit. 
No  meat  should  be  given.  Five  to  15  grains  of  citrate  of  potash  will 
usually  benefit  this  condition.  A  la.xative  should  always  Ijc  given  if  head- 
ache is  due  to  constipation.  Fxercise  and  outdoor  ])hiy  will  aid  this 
condition. 

Jleadarhc  Due  In  Loral  Orlijiii. — Children  frc<|uenllv  complain  of 
headache  which  is  due  to  intra-nasal  neo]»lasms.  At  other  times  such  local 
causes  as  supra-orbital  neuralgia,  due  to  neui'algia  of  the  fifth  cranial 
nerve,  will  cause  an  intense  headache.  In  the  hitter  instance  gentle  mas- 
sage or  a  mild  current  of  farad ic  electricity  will  relieve.  In  severe  cases  the 
internal  administration  of  V'.^^q  grain  of  Duquesnel's  aconitia,  three  times 
a  day,  will  relieve.     In  persistent  headache  it  is  advisable  to  have  the  ears 


SPASMUS    NUTANS.  785 

carefully  examined  b}^  a  coiiijx'feiit.  aurist.     The  freijuency  of  middle-ear 
disease  should  be  borne  in  mind. 

Headache  Due  to  Brain  Lesions. — In  older  children  headache  of  a 
persistent  character,  associated  with  vomiting,  should  always  be  looked 
upon  as  suspicious  of  cerebral  trouble.  A  case  of  this  kind  is  reported  by 
me  in  the  chapter  on  "Cerebro-spinal  Meningitis."'  In  older  children  suf- 
fering with  persistent  headache  it  is  advisable  to  examine  the  fundus  of 
the  eye  to  see  if  a  choked  disc  is  present.  In  one  of  my  cases  a  tumor  of 
the  cerebellum  was  diagnosed  in  this  manner. 

Migraine  (Sick  Headache:  Hemicraxia). 

This  is  a  headache  confined  to  one  side  of  the  head,  associated  with 
dizziness  and  generally  vomiting. 

Causes. — Overworked  school  children  of  a  nervous  type  usually  have 
these  attacks.  Children  suffering  with  dyspeptic  attacks  are  more  fre- 
quently the  victims  of  migraine.  An  indoor  life  in  a  crowded  apartment 
will  cause  this  condition.     Eye  strain  is  frequently  the  eavise. 

Treatment. — Have  the  eyes  examined  and  correct  any  abnormality,  if 
present.  The  diet  should  be  regulated  and  a  laxative  dose  10  to  20  grains 
of  phosphate  of  soda  should  be  given.  The  value  of  bromide  of  soda  in 
Seltzer  water,  with  or  without  caffeine,  should  be  remembered. 

Spasmus  Nutans. 

This  condition  is  frequently  associated  with  rickets.  It  is  characterized 
l)y  an  involuntary  and  uncontrollable  head  shake. 

Etiology. — It  may  be  associated  with  or  follow  traumatism.  Fright 
and  other  psychical  disturbances  may  cause  this  condition.  Heredity  plays 
an  important  part  in  its  development.  It  is  usually  found  associated  with 
rickets.  In  a  case  of  mine  presented  to  the  Section  on  Pediatrics  of  the 
New  York  Academj'^  of  Medicine,^  spasmus  nutans  Avas  associated  with 
sporadic  cretinism. 

Symptoms. — In  some  cases  we  see  a  continuous  nodding,  in  other  cases 
the  motion  is  rotary.  In  rare  cases  both  motions,  nodding  and  rotary,  may 
co-exist.  Nystagmus,  which  is  a  movement  of  the  eyes,  rhythmical  and 
oscillatory,  either  vertical  or  horizontal,  may  also  be  present. 

Prognosis. — Tins  depends  on  the  cause  of  the  same.  As  a  rule  the 
prognosis  is  good. 

Treatment. — If  rickets  is  the  cause  give  the  child  anti-rachitic  treat- 
ment. If  it  is  associated  with  cretinism,  as  in  the  case  reported  by  mc. 
then  give  thyroid  treatment.    A  change  of  air  and  general  restorative  treat- 


'  See  Proceedings  of  New  York  Acadomv  of  Medicine  for  1904. 


786  DISEASES    OF    THE    NERNOIS    SYSTEM. 

ment  is  also  beneficial   in   these  eases.     Electricity  is  not  iudicated  and 
should  not  be  used.     Massage  may  be  tried. 

Stajimkuinc;  and  Stuttering, 

This  is  due  to  a  want  of  eoortli nation  among  the  muscles  concerned 
in  articulation.  The  trouble  may  l)e  eonlined  to  the  lips  and  tongue,  or 
there  may  be  a  laryngeal  spasm,  causing  dilticulty  with  the  vowel  sounds. 

Stuttering  is  usually  due  to  an  affection  of  the  neuro-muscular  mech- 
anism of  articulation  proper;  besides,  the  respiratory  muscles  are  usually 
involved  (Williams).  Defects  of  speech  may  be  hereditary,  although  a 
neurotic  element  may  be  found  in  children  of  neurotic  parents. 

I  have  seen  a  severe  type  of  stuttering-  in  a  child  4  years  old,  whose  father  was 
alcoholic.     Another  case  I  recall  was  seen  as  a  sequela  to  septic  scarlet  fever. 

As  a  rule  it  is  associated  with  some  anatomical  or  pathological  lesion 
in  the  naso-pharynx. 

"Difficulty  with  the  explosive  consonants  is  the  commonest  form,  but 
both  this  and  other  forms  only  become  serious  affections  when  combined 
with  irregular  action  of  the  muscles  of  respiration.  In  such  cases,  during 
the  attempt  to  breathe,  spasm  of  the  muscles  of  the  face,  arms,  and  trunk 
may  occur  and  increase  greatly  the  distress  which  the  patient  suffers." 

Treatment. — Systematic  instruction  in  breathing  and  speaking  by  a 
competent  teacher.  During  singing,  if  attention  is  directed  to  breathing, 
the  defect  is  absent.  Persistent  treatment  by  a  very  patient  teacher  will 
usually  modify  and  benefit  this  condition.  Medication  is  useless  unless  the 
child  is  weak  and  requires  building  up. 

Chorea  (St.  Vitus'  Daxce). 

This  is  a  neurosis  characterized  by  irregular  invohmtary  movements 
of  the  muscles.  It  usually  affects  the  muscles  of  the  extremities,  face,  and 
tongue.    As  a  rule  these  movements  are  not  present  when  the  child  sleeps. 

Etiolo^. — As  a  rule  this  disease  is  most  prevalent  between  the  ages 
of  7  and  11  years.  Chorea  generally  occurs  in  bright  precocious  children. 
It  is  seen  more  than  twice  as  frequent  in  girls  as  in  Ijoys,  and  the  dispro- 
portion becomes  even  greater  after  puberty.  It  is  extremely  rare  in  dark- 
skinned  races.  Chorea  rarely  becomes  chronic,  although  it  recurs  in  about 
one-third  of  the  cases.    It  is  more  likely  to  recur  in  girls. 

Steven  ]\Iackcnzie^  reports  439  cases.  The  largest  number  of  i  tacks 
occurred  in  the  thirteenth  year. 

34  per  cent,  occurred  between 5-10  years 

43  per  cent,  occurred  between    10-15  years 

16  per  cent,  occurred  between    15-20  years 


'British  Medical  Journal,  February,  18S7. 


5 


CHOREA.  787 

Sachs  reported  a  case  seen  in  a  child  under  1  year  of  age,  and  several 
cases  seen  in  children  between  3  and  3  years  of  age.  The  reported  con- 
genital cases  are  usually  mistaken  instances  of  organic  cerebral  disease. 

Sinkler  found  that  of  328  cases,  233  Avere  females,  and  i)G  uiales. 
Gowers  studied  the  statistics  of  1000  cases  and  found  365  in  boys  and  G35 
in  girls. 

Morris  J.  Lewis,  of  Philadelphia,  studied  717  cases  and  found  that 
the  largest  number  occurred  in  March,  the  next  largest  number  in  May, 
and  that  the  curve  corresponds  with  the  rheumatism  curve. 

My  own  experience  is  that  we  have  an  equal  number  of  cases  occurring 
in  the  spring  and  fall  depending  on  the  amuunt  of  study  and  the  sedentary 
life  induced  hy  too  much  school. 

In  a  large  children's  service  among  the  poor  tenement  population,  out 
of  100  cases  of  chorea  examined  by  me  80  cases  occurred  in  females;  20 
cases  in  males. 

All  of  my  cases  were  school  children  who  were  apparently  well  when 
their  chorea  commenced. 

Overstudy  in  School. — Sturges,  in  London,  has  given  considerable  at- 
tention to  the  question  of  overstudy,  and  he  believes  that  it  is  an  impor- 
tant etiological  factor  in  the  causation  of  this  condition.  Overstudy  (ap- 
j)arent)  may  mean  only  inability  to  study  due  to  lack  of  mental  concen- 
tration. 

Chorea  frequently  follows  the  infectious  diseases.  It  is  seen  afler 
scarlet  and  typhoid  fever.  I  have  seen  chorea  of  a  very  severe  type  follow 
a  fright  and  also  after  bad  dreams,  in  school  girls.  Keflex  causes,  such  ns 
phimosis,  pin  worms,  and  delayed  menstruation,  are  cited  by  some  authors. 

Reflex  Causes  Due  to  the  Eye. — I  have  usually  sent  children  suffering 
with  chorea  to  the  eye  specialist  to  see  if  improvement  could  not  be  ob- 
tained by  using  eye-glasses.  1  believe  that  headaches  due  to  astigmatism 
can  be  relieved,  so  also  can  astigmatism  be  modified  when  suitable  glasses 
are  prescribed.  I  do  not  believe  that  the  chorea  per  se  was  cured  in  a 
single  case.  I  do  not  refer  to  those  cases  of  habit  spasm  so  frequently  seen 
in  nervous  children,  hut  1  refer  to  distinct  chorea. 

A  series  of  cases  of  chorea  were  under  the  treatment  and  observation  of 
Dr.  Herman  Jarecky  at  the  IManhattan  Eye  and  Ear  Hospital.  He  re- 
ported no  improvement  directly  due  to  the  wearing  of  eye-glasses. 

Eeflex  conditions,  such  as  adenoids  and  polypoids,  have  been  reported 
from  time  to  time. 

The  reflex  causes  are  overestimated.  Adenoids  are  more  likely  to  in- 
duce tics  rather  than  chorea. 

ISTeurotic  make-up  plays  a  distinct  predisposing  role  (neuroses  or  psy- 
choses in  family). 


788  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Taim^E  No.   101. — 77m'  Associnl ion  of  ('liona    iiilh   l>li(U)ti(ilisiti. 

Steiner   reports 'I'yl  cases  4  siiircrcd   with  rheniiiaUsm 

Sachs  reports 70  t-ascs  8  siilVcrcd  witli  rheumatism 

Sinkler  reports 279  eases  37  siillered  witli  rheuniatism 

Crandall  and  Holt  icport.,    140  eases  03  siill'ered  witli  rheuniatism 

Fischer  reports 100  eases  25  suffered  with  rheumatism 

Tirentij-jive  Per  CeiU.  of  my  Cases  had  Undoubted  Rheuniatism. — 
By  rheumatism  I  include  cases  that  comphiiucd  of  pains  in  or  around  th( 
joints.    At  times  they  were  described  as  "growing  pains"  by  the  parent. 

Frequency  of  Endocarditis. — Valvular  lesions  have  been  seen  by  mi 
in  chorea  without  any  antecedent  joint  lesions.  The  ease  with  which  rheu 
matism  is  overlooked  in  children  makes  the  clinical  history  as  given  b^^ 
parents  doubtful.  It  is,  therefore,  possible  that  there  are  many  more  case 
of  rheumatism  associated  with  chorea  than  are  reported. 

Association  with  Tonsillitis. — Of  the  100  cases  of  chorea  previousl; 
reported*  by  nie,  more  than  80  cases  had  enlarged  tonsils.  It  seems  quit' 
])robable  that  the  tonsil  is  the  point  of  entrance  of  the  pathogenic  bacterii, 
which  cause  chorea,  and  most  probably  rheumatism  and  endocarditis. 

Pathology. — There  are  no  distinct  pathological  lesions  whicli  can  bi 
attributed  to  chorea.  Sachs  sa^^s  that  the  pathology  of  chorea  is  still  i 
great  mystery.  Not  that  autopsies  are  wanting,  but  there  have  been  so  man; 
different  post-mortem  findings  descril:)ed  that  each  writer  may  be  said  t< 
have  his  own  views  concerning  the  pathology  of  chorea. 

Symptoms. — Chorea  usually  begins  with  prodromal  symptoms.  Tb 
children  as  a  rule  are  very  irritable,  depressed,  and  cannot  hold  their  arm 
or  legs  quiet.  They  complain  of  pain  in  various  parts  of  the  body.  Th< 
main  symptoms  which  attract  the  attention  of  parents  or  nurses  are  moto 
disturbances.  These  consist  of  involuntary  twitchings  affecting  variou 
muscles  or  groups  of  muscles.  The  muscles  of  the  hands,  the  legs,  the  facia 
muscles,  and  the  tongue  show  this  choreic  twitching.  At  times  there  is  : 
decided  interference  with  speech.  A  point  worth  noting  is  that  the  chili 
cannot  control  these  movements  voluntarily.  The  greater  the  effort  to  con 
trol  these  movements,  the  more  the  twitching  will  be  noticed.  Sachs  em 
])hasized  the  fact  that  in  doubtful  cases  choreic  movements  of  the  tonga 
will  often  prove  the  nature  of  the  disease.  This  I  have  frequently  been  abl 
to  verify  when  it  was  a  question  of  habit  spasm  or  true  chorea.  There  is  ; 
certain  awkwardness  which  is  typical  in  a  choreic  patient.  This  can  h 
noticed  when  the  child  attempts  to  do  anything.  Choreic  movements  dt 
not  occur  as  a  rule  in  the  night  when  the  child  sleeps,  ^riie  pupils  are  fre 
quently  dilated.  Children  are  sometimes  punished  at  school  for  restlessnes 
which  is  the  beginning  of  true  chorea,  and  it  is  only  later  in  the  disease  tha 
the  true  character  of  the  same  is  detected.  In  some  cases  but  one-half  o 
the  body  (hemi-chorea)  is  affected.    In  other  cases  choreic  movements  ar 


CHOREA.  789 

stronger  iu  the  upper  than  in  the  lower  extremities.  Children  seem  to 
suffer  muscular  weakness  and  there  is  loss  of  muscular  power.  A  peculiarity 
of  chorea  is  that  in  spite  of  the  constant  muscular  twitching  there  is  little 
exhaustion.     The  reflexes  show  no  abnormalit}'. 

Condition  of  the  Heart.— Very  frequently  a  systolic  murmur  has  been 
heard  during  the  course  of  chorea.  This  systolic  murmur  persists  for  months 
after  the  last  symptoms  of  chorea  disappear.  Pains  in  the  large  joints  are 
frequently  described.  1  have  invariably  noted  a  slight  rise  in  the  tem- 
perature (101°  F.)  when  the  joint  pains  or  endocarditis  existed.  When 
chorea  appeared  withoui  evidences  of  cardiac  or  arthritic  complications  the 
temperature  invariably  remains  normal. 

Fannie  S.,  11  years  old,  was  a  very  anaemic  girl.  She  had  been  sick  for  two 
months  with  tonsillitis  and  influenza.  She  was  compelled  to  stay  away  from  school, 
and  in  order  to  catch  up  with  her  class,  studied  very  hard,  especially  at  night,  imtil 
she  passed  her  examinations. 

Histori/  (liven  hij  Mother. — The  child  complained  of  headache,  her  appetite  was 
poor,  the  bowels  constipated.  She  was  restle-ss  by  day  and  did  not  sleep  well  at 
night.  She  had  nervous  twitchings  of  the  arms  and  legs.  Tlie  fingers  were  never 
still.  She  did  not  appear  contented  at  anything.  Her  eyes  were  examined  by  an  ocu- 
list, who  prescribed  eyeglasses.  He  said  the  child  had  eye  strain.  The  mother 
believed  there  was  a  slight  benefit  after  wearing  the  glasses. 

When  the  child  was  brought  to  me,  there  were  distinct  evidences  of  chorea,  with 
twitchings  of  the  face,  the  tongue,  the  hands  and  the  legs.  Four  drops  of  Fowler's 
solution  was  prescribed,  three  times  a  day,  and  gradually  increased  until  7  drops  were 
given  three  times  a  day.  All  school  and  study  was  stopped.  Cold  sponging  and  a 
cold  shower  was  ordered  every  morning  and  evening.  Cereals,  vegetables,  milk,  and 
fruit  were  given.  All  meat  was  stopped.  An  active  outdoor  life  and  all  quiet  g-ames 
and  sports  were  recommended.  Under  this  treatment  the  symptoms  gradually  sub- 
sided and  the  child  recovered.  One  year  later  the  same  symptoms  returned,  and  it 
was  found  that  the  cause  of  the  relapse  was  ovearstudy.  I  prescribed  "remove  the 
cause,"  namely,  take  the  girl  away  from  school. 

Course. — The  usual  course  of  this  disease  is  from  six  to  ten  weeks, 
although  it  may  extend  to  four  months.  I  have  seen  cases  in  which  there 
was  a  severe  attack  in  the  spring,  which  seemed  to  disappear  entirely  dur- 
ing tiio  siiiniiu'r,  and  suddenly  reappear  with  greater  intensity  in  the  fall. 

Prognosis. — Tlie  outcome  of  a  case  of  chorea  is  usually  good,  e-pecially 
so  if  Ave  are  dealing  with  intelligent  motbers  and  nurses.  The  prognosis  is 
bad  if  endocarditis  or  other  organic  lesions  are  associated. 

Treatment. — Be.^t  Treatment. — It  is  useless  to  attempt  to  modify  se- 
vere or  mild  chorea  without  enjoining  absolute  rest  in  bed.  The  eyes  should 
be  protected  from  a  strong  light,  or  tbe  room  sbould  be  darkened  by  drawing 
the  shades.  In  some  cases  1  have  ke|)t  cbildreii  in  bed  for  one  week  before 
tlie  twitchings  ceased.  In  sexerer  cases  it  may  be  necessary  to  keep  a  child 
in  bed  at  least  two  or  more  weeks.  TJie  soolhiiuj  in/laenrc  of  tJii.s  absolute 
rest  in  bed  will  do  more  good  tban  all  tlie  dru<is  combined. 


790  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Hygienic  Trcalnivnt. — A  cliiKl  should  be  removed  from  school  and 
thus  guarded  against  all  2)syehii-al  disturbances.  Cold  sponging  of  the  en- 
tire body  and  cold  spinal  douches  have  been  found  very  beneficial. 

The  diet  should  be  light  and  very  nutritious.  All  cereals  should  be 
given  (see  diet  list  for  a  child  from  3  to  10  years  old,  page  154).  Meat 
should  be  avoided,  although  meat  soups  and  white  meat  or  chicken  may  be 
permitted.  Later  fresh  air  and  quiet  out-of-door  exercise,  games,  and  sports 
are  necessary  adjuncts  in  the  treatiuent  of  this  disease. 

Medicinal  Treatment. — Iron  and  arsenic  should  always  be  remem- 
bered in  the  treatment  of  this  disease.  We  can  begin  with  4  or  5  drops  of 
Fowler's  solution,  three  times  a  day,  and  watch  the  systemic  effect,  with 
gradually  increasing  doses  until  10  drops,  three  times  a  day,  are  given. 
Great  care  should  be  nsed  to  avoid  arsenical  poisoning  when  large  doses  of 
Fowler's  solution  are  given.  In  some  children  a  peculiar  idiosyncrasy 
exists  which  renders  them  lial)le  to  systemic  poisoning.  Semple  has  re- 
jjorted  multiple  neurit's  following  the  use  of  arsenic  in  the  treatment  of 
chorea.  I  have  seen  multiple  neuritis  in  a  rachitic  child  having  chorea 
minor.  The  child  received  4  drops  of  Fowler's  solution  for  six  weeks. 
When  the  arsenic  was  withdrawn,  the  neuritis  subsided.  Of  the  prepara- 
tions of  iron  on  the  market,  ncoferrum  in  doses  of  1  or  3  teaspoonfuls  has 
served  me  very  well.  Another  preparation  which  I  have  frequently  nsed  is 
the  liquor  ferri  peptomangan  (Gude)  in  doses  of  a  teaspoonful,  three  times 
a  day,  after  meals.  Ferratin,  5  to  10-grain  doses,  three  times  a  day,  after 
meals,  is  also  beneficial.  Antipyrin  and  bromide  of  sodium  may  also  be 
nsed  in  some  cases.  When  chorea  is  associated  with  rheumatism,  the  salicy- 
late of  soda  in  3  to  5-grain  doses,  or  salipyrin  in  the  same  quantity,  may 
be  given  three  or  four  times  a  day.  Some  authors  advise  against  the  use 
of  chloral  hydrate;  my  personal  experience  with  2-gTain  doses  of  chloral 
hydrate  given  morning  and  evening  has  been  very  good.  If  choreic  twitch- 
ing does  not  improve  after  several  weeks  of  persistent  treatment,  then  a 
cold  pack  may  be  tried.  A  sheet  wrung  out  in  cold  water  at  a  temperature 
of  60°  F.  should  be  wrapped  around  the  child  for  one  hour  every  morning 
and  evening.  Not  only  have  I  seen  a  soothing  effect  on  the  nervous  system 
from  these  packs,  ])ut  they  frequently  promote  sleep.  That  electricity  is  of 
value  in  this  condition  is  doul)ted  by  many.  I  have  seen  one  or  two  cases  in 
which  excellent  results  were  obtained  from  the  use  of  a  weak  galvanic  cur- 
rent over  the  spinal  nerves.  On  the  other  hand  I  have  frequently  seen  no 
effect  whatsoever  from  the  treatment  with  mild  or  strong  galvanic  currents. 

Sachs  recommends  hyoscyamin  in  ta])lct  form,  Yj^o  grain,  when  rest- 
lessness and  insomnia  exist.  Hyoscyamin  should  only  be  administered  in 
the  afternoon  and  evening.  jMassage  is  sometimes  of  value  in  conjunction 
with  electricity;   it  has  a  soothing  effect  on  the  nervous  system  and  stimu- 


HYSTERIA.  791 

lates  nutrition.     It  is  especially  valuable  at  night  and  I  have  seen  a  pro- 
found sleep  follow  thorough  massage  of  the  body. 

Hysteria. 

It  is  an  important  matter  to  recognize  this  condition  when  met  with 
in  children.  It  is  rarely  seen  in  children  under  7  years  of  age,  although 
cases  are  on  record  of  distinct  hysteria  having  been  met  with  in  infancy. 
In  my  experience  children  rarely  simulate  disease.  I  have  seen  children 
imitate  an  invalid  mother  and  complain  of  inuiginary  pains  and  aches  at 
the  same  time  and  in  the  same  portions  of  the  body  as  the  mother.  Very 
neurotic  children,  susceptible  children,  and  children  having  bad  habits,  such 
as  masturbation,  are  more  prone  to  develop  hysteria.  Charcot  maintained 
that  hysterical  persons  are  hysterical  l)ecause  they  are  mentally  degenerate. 

Pathology. — Hysteria  is  not  a  fatal  disease,  hence  we  have  no  specific 
jjathological  lesions.  The  theory  concerning  the  mobility  of  the  neuron, 
while  very  interesting  and  scientific,  does  not  explain  the  hysterical  par- 
oxysms. Hysteria  is  not  a  psychosis  as  is  generally  sup})osed.  There  are  no 
known  demonstrable  lesions.  While  in  some  cases  the  whole  brain  seems 
disturl)ed  and  involved,  in  other  cases  but  one-half  of  the  l)rain  is  involved. 

Symptoms  and  Diagnosis.- — ^Paralyses  occur  in  hysteria  which  simulate 
those  due  to  central  nervous  disease.  As  a  rule,  however,  they  disappear. 
The  hysterical  paroxysm  usually  follows  close  upon  an  aura.  It  sometimes 
comes  on  suddenly,  although  it  may  be  preceded  by  a  spell  of  laughing  or 
crying.  Children  old  enough  to  complain  describe  a  "lump  in  the  throat" 
similar  to  the  "globus  hystericus"  which  occurs  in  the  adult. 

Some  symptoms  closely  resemble  epilepsy.  Headache  is  complained 
of  at  times.  The  screaming  and  shouting  gradually  cease  as  the  attack 
subsides.  Tlie  following  description  given  by  Taylor  and  Wells  describes 
the  attack  so  closely  that  I  repeat  it:  "The  patient  sinks  down  or  falls 
])ror,e  upon  the  back,  with  the  limbs  extended  and  rigid,  but  with  the  fingers 
and  toes  flexed;  the  eyes  are  usually  rolled  slowly  from  right  to  left,  or 
crossed;  the  jaws  arc  firndy  closed;  the  breathing  becomes  slow  and 
labored,  and  later  hurried,  the  face  flushed  or  bluish,  the  neck  turgid;  the 
cardiac  action  becomes  more  rapid  and  forcible,  and  consciousness  is 
almost,  ])ut  never  entiro>ly.  lost.  Sensation  is  much  obtunded,  and  abolished 
in  some  portions  of  the  body.  Soon  clonic  movements  succeed — a  tremor 
affecting  tl;e  muscles  of  the  trunk,  extremities,  and  face.  This  alternates 
vvitli  electric-like  starlings,  during  which  the  jiatient  may  fling  himself 
furiously  about,  or  actually  out  of  bed.  l^resently  this  stage  ends  with 
sighs,  and  is  followed  by  a  short  sleep."  Some  authors  describe  a  series 
of  dramatic  movements.  There  may  be  op'sthotonos.  The  child  may  have 
a  bowing  of  the  lumbar  curve  so  fliat   if    rests  u]k)ii   its  head  and  heeU 


792  DISEASES    OF    THE    NERNOLS    SYSTEM. 

There  may  be  a  series  of  attacks  recurring  so  that  as  many  as  two  hundre^i 
paroxysms  have  been  recorded  by  Sachs.  I  have  seen  a  severe  form  of 
hysteria  with  over  ten  paroxysms  during  one  hour.  Some  tender  areas 
frequently  noted  in  children,  over  the  ovaries  and  spine  in  girls,  and  the 
testicles  of  boys,  are  very  sensitive.  Some  authors  claim  that  pressure  over 
these  areas  will  sometimes  invite  an  attack  of  hysteria;  on  the  other  hand 
pressure  over  these  same  sensitive  areas  will  sometimes  stop  an  attack. 

Vomiting  when  it  does  occur  is  a  very  serious  symptom.  We  do  not 
have  the  same  forms  of  tremor  as  are  seen  in  adults. 

Borborigmus  (rumbling  gas  in  the  intestines)  is  occasionally  heard  in 
this  condition. 

Epidemics  of  hysteria  are  frequently  descri])ed.      J.  Madison  Taylor 
describes  one  occurring  in  a  church  home  at  Philadelphia.      I  have  fre- 
quently seen  children  in  one  locality  suffer  with  various  manifestations  of- 
hysteria,  in  which  we  could  easily  trace  the  origin  to  one  particular  child. 

Prognosis  and  Course. — The  duration  of  the  disease  depends  on  the 
surroundings  of  the  child.  ]\Iild  hysteria  will  sometimes  disappear  after  a 
change  of  scene  and  air  of  several  weeks.  In  some  instances  a  case  may 
last  years  or  through  the  child's  whole  life. 

It  is  always  well  to  remember  that  hysteria  is  difficult  to  cure.     If  a  ' 
child  is  sensitive  and  subjected  to  impressions  from  a  neurotic  family,  then 
a  cure  will  be  difficult.     The  outcome  of  any  case  of  hysteria  depends  on 
the  character  of  the  surroundings  and  on  the  mental  influences  with  which 
the  child  is  Ijrought  in  contact,  rather  than  on  drug  treatment. 

Case  I. — A  girl  9  years  old  was  brought  to  me  for  the  relief  of  headache.  She 
complained  of  a  continual  headache  night  and  day.  The  appetite  was  poor,  the 
bowels  moverl  sluggishly.  She  was  restless  during  the  day,  and  had  insomnia  at  night.  [ 
She  complaine<l  of  bad  dreams.  She  looked  haggard  and  worn,  as  though  she  [ 
were  convalescing  from  some  severe  illness.  She  was  anaemic  and  had  cold  extremi- 
ties. Heart,  lungs,  liver,  and  spleen  were  normal.  She  was  a  very  restless  child  with 
marked  hyperaesthesia.     The  patellar  reflexes  were  exaggerated. 

Siihjective  f^ifiuptonift. — The  child  complained  of  pain  in  every  part  of  her  body. 
On  being  asked,  "Does  your  side  hurt?*'  she  answered,  "Yes,  my  pains  are  in  the  side 
and  in  the  back,  just  like  my  mother's."  I  referred  the  child  to  an  oculist  for  an 
ojiinion  as  to  the  eyes,  and  his  answer  was:  nothing  abnormal,  no  astigmatism.  The 
child  cried  on  the  slightest  provocation,  and  was  also  almost  convulsed  with  laughter 
for  trivial  matters.  The  diagnosis  was  hysteria.  The  child  had  a  headache,  or  a 
backache,  and  always  complained  of  some  ache.  It  was  quite  evident  that  the  child's 
hysteria  was  due  to  suffgestion  hi/  the  mother,  who  was  an  invalid. 

The  treatment  consisted  in  removing  the  child  to  an  aunt  in  a  neighboring  city, 
amid  healthy  surroundings.  Iron  was  ordered  to  build  up  the  system,  and  bromide 
of  so*la  in  lO-grain  doses  was  given  every  night  for  one  week,  later  every  other  night. 
Electricity,  the  baths,  and  massage  were  usecl  with  great  success.  Tn  three  months 
the  child  had  rosy  cheeks,  slept  well,  was  cheerful,  and  did  not  complain  of  any  pain. 
It  was  strange,  however,  that  Avlicn  taken  back  to  her  mnfhcr.  she  immediately  re- 


II 


MULTIPLE    NEUPvlTlS.  793 

lapsed  into  her  former  habit  of  complaining.  We  determined  to  remove  her  per- 
manently, and  she  remained  well  for  over  a  year  when  I  last  heard  of  her. 

Case  11.^ — General  Hysteria  and  Nervous  Vomiting. — A  girl  12  years  old  was 
brought  to  my  cliildren's  clinic  for  the  relief  of  vomiting.  She  was  very  nervous 
and  complained  of  pains  all  over  her  body.  She  complained  also  of  pains  in  her 
stomach  before  and  after  eating.  Her  mental  condition  was  poor,  the  hands  and 
feet  were  cold.  She  complained  of  epigastric  pains  for  the  last  six  years.  From 
the  mother  I  learned  that  the  child  was  frightened  by  a  dog  and  since  that  time  slie 
has  been  very  sensitive  to  the  slightest  impression.  The  gastric  contents  were 
syphoned  off  after  a  test  meal  and  a  hyperchlorhydria  was  found.  The  urine  con- 
tained acetone. 

The  treatment  of  this  case  was  most  successful  when  large  doses  of  bromides 
were  given. 

Treatment.- — Study  the  cause  or  causes,  and  remove  them  if  possible. 
Change  the  surroundings  of  the  child  by  removing  to  a  cheerful  l)ut  quiet 
home.  If  the  case  occurs  in  the  country,  bring  the  child  to  the  city.  In 
any  event  the  main  point  should  bo  to  change  the  entire  scene  and  sur- 
roundings. If  a  child  is  in  an  institution,  remove  it  from  the  same  if  it 
is  at  all  possible.  The  person  in  charge  of  the  child  should  be  either  a 
very  intelligent  mother  having  a  positive  influence  over  the  child,  or  a 
mild-mannered  trained  nurse.  All  orders  of  the  physician  should  be 
strictly  obeyed  Avithout  having  the  child  feel  that  vigorous  treatment  is 
being  used.  This  psychosis  requires  educational  treatment  as  has  just  been 
described. 

Hygienic  Treatment. — If  the  child  is  old  enough,  a  walk  should  be 
ordered  several  times  a  day.  The  bicycle  and  horseback  are  valuable  ad- 
juncts. The  sponge  bath  or  the  tub-bath  aided  by  a  cold  shower  or  spray 
chiefly  over  the  spine,  head,  and  neck,  have  very  tonic  properties. 

Hydrotherapy  properly  used  is  one  of  the  most  valuable  aids  in  pro- 
moting a  cure. 

Xothwithstancling  the  shock  of  a  cold  spray,  the  same  should  be  ordered 
winter  or  summer. 

After  the  bath  the  body  should  l)e  rubl)cd  vigorously,  or  better  yet, 
massage  should  be  given.  I  have  always  found  a  very  soothing  effect  on 
the  nervous  system  by  giving  gentle  but  thorough  massage.  Another  reme- 
dial agent  wdiich  must  be  used  regularly  is  electricity.  This  should  l)e  used 
daily  by  means  of  a  mild  faradic  current,  one  electrode  to  be  applied  over 
the  spine,  the  other  over  the  phrenic  nerve.  If  no  bonofit  is  noticed  after 
this  treatment  is  tried,  then  static  electricity  can  be  used. 

]\rrLTii'LH  Xi:ri{iris   (  ['oi-Ynkikitis). 
This  is  frequently  termed  a  ])('ri])]K'rnl   neuritis,  as  it  is  an  affection 
of  the  terminal  liraiu-hos  of  Ihc  nerves.      li    usiiallv  afTeeis  all   ihe  nerves 


'This   case   was    prcscnlcil    by    iiic    (<i    llic    Snl  ion    dn    T^'(]ia^l•ics,    Academy   of 
Medicine,  February  14.  1001. 


794  DISEASES    OF    THE    NERVOUS    SYSTEM. 

of  the  limbs  ou  both  sides  of  the  body.  Starr  gives  the  following  classifica- 
tion : — 

''1.  Toxic  cases  due  to  the  action  of  a  poison  derived  from  without 
the  body.  These  poisons  are  alcohol^  carbonic  oxide  gas,  bisulphide  of  car- 
bon, the  coal-tar  products,  especially  sulphonal  and  trional;  and  nitro- 
benzol;    also,  arsenic,  lead,  mercury,  copper,  phosphorus,  and  silver. 

"2.  Infectious  cases  due  to  some  agent  acquired  or  developed  within 
the  body,  as  an  accompaniment  or  sequel  of  diphtlieria,  grippe,  typhoid, 
typhus,  malaria,  scarlet  fever,  measles,  whooping-cough,  smallpox,  erysipe- 
las, and  septicemic  conditions,  including  gouorrluea  and  puerperal  fever, 
epidemic  forms  of  beriberi   or  kakke,   and   leprous  neuritis. 

"3.  Cases  due  to  general  diseased  states  of  the  body  whose  origin  is 
undetermined,  such  as  rheumatism,  gout,  diabetes,  au^emia,  marasmus,  gen- 
eral malnutrition  consequent  upon  tuberculosis,  syphilis  and  senility,  car- 
cinoma, and  local  malnutrition  produced  by  arterial  sclerosis. 

"4.  Cases  due  to  exposure  to  cold  and  developing  spontaneously  with- 
out known  cause." 

The  most  common  type  of  multiple  neuritis  met  with  in  children  U 
either  the  diphtheritic  type  or  that  resulting  from  poisons  in  the  blood. 
such  as  the  prolonged  administration  of  Fowler's  solution  (arsenical  poi- 
soning). 

Symptoms  and  Diagnosis. — Multiple  neuritis  uuiy  come  on  suddenly 
or  the  onset  may  be  gradual.  The  special  senses  are  rarely  involved  in 
this  condition.  The  motor  symptoms  are  as  marked  as  the  sensory.  Paral- 
ysis comes  on  first  as  a  mjiscle  weakness,  and  gradually  increases  until  dis- 
tinct paralysis  is  present.  The  extensor  muscles  of  the  wrist,  hands,  ami 
feet  give  the  wrist-drop  and  the  foot-drop.  Very  rarely  the  muscles  of  all 
four  extremities  in  addition  to  the  muscles  of  the  trunk  and  neck  are  in- 
volved. The  knee-jerk  usually  disappears  early  when  neuritis  follows  diph- 
theria. The  paralyzed  muscles  are  relaxed,  flabby,  and  atrophied.  An 
important  symptom  is  that  faradic  excitability  is  absent  and  that  the  nms- 
cles  respond  to  a  galvanic  current  only.  This  symptom  is  identical  with 
that  found  in  acute  anterior  ])oIiomyelitis.  The  reaction  of  degeneration  is 
present. 

There  is  usually  no  incontinence  of  bladder  and  bowel.  Atrophy  is 
another  prominent  symptom.  The  condition  is  similar  to  that  seen  in 
poliomyelitis.  There  may  be  other  vasomotor  disturbances  such  as  uni- 
lateral flushing  of  the  skin,  or  small  areas  may  show  a  high  glossy  flush. 
This  last  symptom  was  very  ])roni incut  in  one  of  my  cases.  An  cedema 
of  the  affected  parts  is  described  by  som(!  authors.  As  a  rule  the  areas 
affected  are  very  sensitive,  so  that  we  have  distinct  hypera^sthesia.  In  other 
cases  the  opposite  condition  prevails  and  there  are  areas  of  local  anaesthe- 
sia.    The  disease  may  be  ushered  in  by  a  fever.     The  temperature  may  rise 


I 


PAYOR    ^OCTURNUS.  795 

to  103°  or  104°  F.,  and  remain  several  days.  The  pulse-rate  is  correspond- 
ingly increased  and  may  reach  140  or  160. 

Gastric  disturbances  associated  with  diarrhcea  may  be  present.  The 
spleen  is  frequently  enlarged,  and  an  examination  of  the  blood  will  show 
a  distinct  leucocytosis,  the  latter  condition  when  neuritis  is  a  sequela  to 
an  infectious  disease. 

Course  and  Prognosis. — As  a  rule,  multiple  neuritis  lasts  from  several 
weeks  to  several  months,  and  then  ends  in  recovery.  The  eases  seen  by  me 
associated  with  chorea  in  which  arsenical  poisoning  took  place,  invariably 
improved  when  the  drug  was  withheld  for  a  short  time.  Earely  does  the 
paralysis  remain  j^ermanent.  The  prognosis  can  best  be  gauged  by  noting 
the  electrical  reactions.  If  the  reaction  of  degeneration  is  present  after 
the  disease  has  lasted  several  months,  then  a  permanent  lesion  must  be 
suspected.  If,  on  the  other  hand,  there  is  only  a  slight  difference  in  the 
reaction  following  the  use  of  the  faradifl  current,  then  a  complete  recovery 
may  be  expected.  Some  cases,  although  severely  atrophied,  will  ultimately 
recover.     If  myelitis  complicates  this  condition,  the  prognosis  is  serious. 

Treatment. — The  system  should  be  strengthened  with  proper  nutrition. 
The  patient  should  be  made  as  comfortable  as  possible.  If  severe  pains 
exist,  then  large  doses  of  bromide  should  be  given,  with  or  without  codeine, 
until  all  pain  is  relieved.  In  some  cases  the  local  application  of  warmth 
over  the  affected  limb  is  very  soothing.  I  frequently  use  a  warm  bath  at 
night,  which  is  very  soothing  and  ]3romotes  sleep. 

Gentle  friction  and  massage  are  beneficial.  Eestoratives,  such  as  cod- 
liver-oil,  maltine  with  hypophosphites,  and  iron  should  be  used.  The 
syrup  of  the  iodide  of  iron  is  a  good  restorative.  Butter,  cream,  and 
cereals  are  excellent  tonics.  Strychnine  and  nux  vomica  are  valuable  if 
the  appetite  is  poor ;  otherwise  they  have  no  specific  value. 

Pavok  Xocturxus  (Xight  Tkkrors). 

Children  apparently  healthy  will  ^onu'tinK's  awaken  from  a  sound 
sleep  and  shriek  or  scream. 

Etiology. — In  this  condition  children  usually  show  some  disturbance 
of  the  stomach  or  bowels  which  may  have  been  the  exciting  cause  of  the 
night  terror.  Iicflex  irritability  is  fre({uently  caused  by  intestinal  worms, 
))y  adenoid  vegetation,  or  in  the  male  child  by  an  elongated  prepuce,  or 
by  phimosis.  Such  children  usually  ])Ossess  a  r.euro])athic  constitution  by 
inheritance.  Henoch  states  that  <ome  cldldren  may  have  hallucinations 
during  the  day.  '^I'hcse  attacks  occur  Iiut  once  during  the  night,  and  afl^cr 
reassuring  the  child  ihat  there  is  no  danger,  i1  will  again  fall  asleep. 

Symptoms. — Some  children  awaken  frightened  and  screaming,  while 
i)thei>  will  grasj)  anything  within  reach  in  a  bewildered  manner.     They 


796  DISEASES    OF    THE    NER\OUS    SYSTEM. 

frequently  imagine  that  animals  are  in  the  room.  The  effect  of  too  rigid 
discipline  will  sometimes  show  itself  by  bad  dreams  at  night,  and  in  a 
distinct  hysterical  symptom,  such  as  fright  and  terror. 

Course  and  Prognosis. — If  these  night  terrors  are  associated  with  mild 
nervous  attacks  during  the  day,  or  if  they  partake  of  the  nature  of  epileptic 
attacks,  then  a  cautious  prognosis  should  be  given.  The  inclination  to 
serious  brain  or  nervous  trouble  must  always  be  remembered;  therefore, 
no  opinion  should  be  ventured  until  a  case  has  been  properly  observed. 

Treatment. — Children  having  night  terrors  should  be  removed  from 
school  to  insure  perfect  tranquillity.  There  should  be  a  distinct  change  of 
scene,  a  change  from  the  city  to  the  country,  or  vice  versa,  will  be  bene- 
ficial. Any  reflex  cause,  if  present,  should  be  attended  to,  and,  if  possible, 
removed.  Fresh  air,  out-of-door  life,  and  restoratives  are  indicated.  Such 
children  appear  less  frightened  if  they  sleep  in  the  room  with  an  adult, 
and  are  thus  reassured  that  there  is  no  danger  present. 

Cold  or  gradually  cooled  bathing  or  a  spray  over  the  spine  will  tone' 
the  nervous  system.  It  should  be  used  in  a  warm  room  daily.  Five  grains' 
of  sodium  bromide  may  be  given  before  retiring. 

Masturbation  (Onanism) . 

This  habit  is  very  frequently  seen  in  children.  I  have  seen  it  in  girls 
as  well  as  in  boys. 

Causes. — Any  irritation  of  the  genital  tract  that  will  cause  itching 
may  be  the  origin  of  masturbation.  In  boys  an  elongated  prepuce,  or 
friction  from  phimosis,  may  give  rise  to  this  condition.  Very  acid  urine 
may  cause  excoriation  and  thus  invite  this  bad  habit.  Excoriations  at  oi  i 
near  the  external  meatus  may  be  the  starting  point.  We  see  this  condition 
quite  frequently  in  girls  when  preputial  adhesions  due  to  smegma  or  dirl 
cause  an  irritation  of  the  clitoris  or  when  pin  worms  wander  from  the  anu^ 
to  the  vagina;  thus  worms  frequently  set  up  an  irritation  resulting  in  mas- 
turbation. A  diaper  if  too  tightly  pinned  can  set  up  an  irritation,  especiall} 
in  female  children. 

Symptoms. — Children  usually  place  their  hands  on  the  genitals  an( 
masturbate.  They  sometimes  rub  their  thighs  together  until  exhausted 
During  this  friction  their  face  will  be  flushed  and  they  appear  irrital)lr 

Such  children  sutfer  with  profound  anaemia  as  the  result  of  this  habit 
and  from  loss  of  sleep.  Older  cliildren,  especially  boys,  will  masturbat' 
chiefly  at  bedtime.     They  are  peevish,  irritable,  and  very  sensitive. 

An  infant  al)oiit  nino  niondis  old  was  socn  by  nip  in  fonsiiltation  \vitli  Dr.  I 
F.  Harris,  of  New  York  City.  Tiic  niotlicr  coniplainod  tliat  the  cliild  continual!; 
rubbed  ils  thighs.  The  face  was  flushed  during  the  rubbing;  later  the  child  wouii 
fall  asleep  as  though  from  exhaustion.      Tliis  condition  seemed  to  occur  chiefly  whei 


11 


MASTURBATION.  797 

the  child  was  placed  011  the  bed  or  held  uii  the  lap.     An  examination  of  the  genitals 
showe<l  that  they  were  very  red  and  excoriated  frojn  the  constant  irritation. 

The  prognosis  is  usually  good  if  the  luibit  is  detected  early  and  the 
cause  removed  if  one  exists.  On  the  other  hand,  some  cases  will  persist 
in  spite  of  careful  treatment,  and  nothing  but  heroic  measures  will  effect 
a  cure,  as  the  following  case  will  illustrate: — 

An  infant,  female,  was  brought  to  me  for  the  relief  of  this  condition.  The 
child  had  mastiubated  continually  for  several  months  and  was  so  emaciated  that 
the  parents  were  alarmed.  The  condition  was  so  bad  that  the  child  masturbated 
whenever  the  thighs  were  put  together.  A  pad  was  improvised  to  separate  the  thighs 
and  local  applications  of  lead  water  on  cotton  were  placed  over  the  genitals  to  reduce 
the  irritation.  Large  doses  of  bromides  were  administered  to  control  irritability  in 
the  nervous  system.  The  child  was  kept  in  a  stupor  for  several  days  without  having 
the  condition  relieved.  The  sjTnptoms  persisted  and  we  finally  were  compelled  to 
remove  the  child  to  the  St.  ^larks  Hospital  where  Dr.  H.  J.  Garrigues  suggested  per- 
forming a  clitoridectomy.  This  case  was  published  in  extenso  in  Archives  of 
Pediatrics,  May,  1899.  The  child  made  a  perfect  recovery.  The  habit  did  not 
reappear. 

Treatment. — Ecmove  the  cause  if  any  exists.  All  irritants,  such  as 
worms  or  eczema,  should  1)e  treated.  If  an  enlarged  prepuce  causes  this 
condition,  remove  it.  If  a  vaginal  discharge  exists,  treat  it  with  astrin- 
gents, and  thus  avoid  irritation.  If  worms  are  present,  injections  of  quassia 
will  dislodge  them  (see  chapter  on  "Worms").  In  older  children  we  must 
remove  the  child  from  bad  company,  and  sometimes  it  will  be  necessary  to 
change  the  entire  surroundings  of  a  sensitive  l)ut  well-meaning  child.  An 
ocean  voyage  is  beneficial.  The  system  should  be  strengthened  by  giving 
iron  and  strychnine.  Clean  habits,  a  rigid  hygiene,  and'  a  daily  bath  are 
necessary.  Strict  supervision  by  night  as  well  as  by  day  v/ith  the  aid  of 
a  trained  nurse  will  do  more  good  than  medicine.  Children  once  detected 
v.-ith  this  bad  habit  juust  never  be  permitted  to  sleep  with  their  hands  under 
the  bedclothes. 

r'inumcisioji  is  one  of  llie  most  valuable  means  of  curing  this  hal)it. 
In  females,  especially  in  little  girls,  stripping  the  clitoris  and  cleansing  the 
smegma,  if  present,  will  fretpu'utly  modify  this  habit.  If  the  habit  persists 
in  s))ite  of  this  treatment,  then  a  i-adieal  operation  (sec  clinical  case  given) 
nuiy  be  reqnirc-d. 


CHAPTER  III. 
TETANY. 

Tetany  is  a  nervous  disorder  eliaraeterized  1)Y  tonic  spasms,  chieflx 
affecting  the  hands  and  feet.  They  are  known  as  earpo-pedal  contraction^ 
or  sometimes  as  arthrogryposis. 

Etiology. — Intestinal  to.xannia  is  presumed  to  l:)e  tlie  etiological  factor 
Tetany  is  usually  found  in  infants  under  2  years  of  age.  Laryngismus 
stridulus  is  frequently  associated  with  it. 

It  is  intimately  associated  witli  rickets  and  witli  other  diseases  resultini 
from  improper  nutrition,  such  as  atlirepsia  and  dyspeptic  conditions.  It 
frequently  follows  diseases  which  exhaust  tlie  vitality  of  an  infant,  sucl 


Fig.  257. — Tetany.  Characteristic  attitude  of  the  hands  resembling  a 
rider  reining  in  his  horse.  Note  attitude  of  the  toes.  The  wrists  are 
rigid  and  flexed.  The  elbows  are  free.  The  fingers  are  flexed  at  the  meta- 
carpal-phalangeal joints.  In  this  case  facial  irritability  was  best  seen  by 
constant  spasm  in  the  orbicularis  paljjebrarum.      (Original.) 

as  broncho-pneumonia,  typhoid,  or  whooping-cough.    It  is  very  often  noted 
when  these  diseases  have  lasted  a  long  time. 

Facial  irritability  is  not  uncommon  in  older  children,  and  it  occurs 
with  them  not  only  in  tetany  and  certain  other  nervous  conditions,  but 
with  slight  dyspeptic  disorders,  and  sometimes  a))art  from  any  ascertain- 
able disease.  In  young  ch'ldren  it  is  common,  but  it  is  rarely,  if  ever, 
found  before  the  sixth  mc  ith.  It  occurs  in  most  cases  of  laryngismus. 
When  met  with  alone  in  cialdren  under  3  years  old  who  have  any  sign  of 
rickets,  it  may,  practically  always,  be  regarded  as  a  danger  signal,  showing 
a  state  of  abnormal  nervous  excitability  and  a  probable  tendency  to  more 
serious  neuroses.  Under  these  circumstances,  therefore,  it  must  be  taken 
(798) 


TETANY.  799 

as  an  indication  for  prompt  sedative,  tonic,  and  especially  anti-racliitie 
treatment. 

Symptoms. — If  we  tap  the  muscles  of  the  jaw,  a  slight  contraction  of 
the  face  ensues.  This  is  known  as  the  facial  phenomenon,  and  was  first 
described  by  Chvostck.  The  contractions  are  first  seen  in  the  orbicularis 
palpebrarum. 

The  contraction  resembles  that  caused  by  the  sudden  passage  of  a 
galvanic  current.  It  is  sometimes  more  marked  on  one  side  of  the  face 
tlian  the  other;  and,  in  some  cases,  it  is  more  noticeable  in  the  upper;  in 
others,  in  the  lower  half  of  the  face.  A  similar  contraction  of  the  inner 
end  of  the  eyebrow  may  often  be  caused  by  tapping  on  the  temple.  The 
wrists  are  rigid  and  flexed.  The  elbows  are  free.  The  fingers  are  flexed 
at  their  metacarpo-phalangeal  joints.  There  may  be  a  constant  spasm, 
jerking  in  character,  continually  present. 

A  similar  phenomenon  is  known  as  Trossean's  sign  :  if  the  arm  is  com- 
pressed by  an  elastic  ])and  the  muscles  of  the  fingers  and  sometimes  of  the 
forearm  pass  into  tlie  tetanic  condition. 

Kassowitz  maintains  tiiat  laryngeal  spasm  is  a  symptom  of  tetany  and 
tbat  its  occurrence  is  pathognomonic. 

Course. — The  course  of  this  disease  is  given  by  some  authors  as  from 
a  few  days  to  several  weeks.  In  one  case  observed  by  me  at  the  Willard 
Parker  Hospital  (see  Fig.  25T),  the  tetanic  spasms  lasted  for  more  than  two 
months.  Other  cases  seen  by  me  lasted  but  a  few  days  or  weeks  at  the 
longest. 

Prognosis. — The  prognosis  is  excellent  if  the  cause  of  the  tetany  is  a 
gastro-intestinal  disorder. 

There  are  instances  in  which  death  has  ensued  from  laryngeal  spasm 
or  from  general  convulsions,  ^^'hen  a  very  frail  infant  lias  severe  tetany 
of  the  upper  and  lower  extremities  with  retraction  of  the  head,  then  the 
prognosis  is  bad. 

Gowers  reports  cases  of  tetany  followed  l)y  muscular  atrophy. 

Treatment. — It  is  advisable  to  cleanse  the  gastro-intestinal  tract  by 
giving  calomel  from  V2  fo  1  grain,  repeated  if  necessaryo  Castor-oil  is  a 
safe  remedy.  Ehubarl)  and  soda  is  also  a  good  corrective.  If  the  child 
is  over  1  year  old.  then  a  wineglassful  of  citrate  of  magnesia  will  be  useful. 

Stomach  icashing  should  not  he  resorted  to,  as  there  is  a  risk  of  causing 
laryngeal  spasm  by  tins  ])roccdiire.  If  the  child  cries  owing  to  jiain  caused 
by  the  tetanic  spasm,  tlien  cbMral  and  bromide  sbould  be  given.  A  .varm 
bath  is  generally  well  borne.  Belladonna  or  atropine  is  useful  when  given 
in  full  doses.  Salol  and  bismuth  with  calcined  magnesia  are  very  good 
intestinal   antiseptics. 

Tetanoid  condition  has  been   reported   by  ]\raestro  after  the  extirpa- 


800  DISEASES    OF    THE    NERVOUS    SYSTEM. 

tioii  (if  I  he  (livroid  Inland.      P'or  (his  rrason  llu.'  exlraeiui'  lliu  tlivroid  gland 
has  Ut'CJi  a(-l\tK-ak'd  J'or  tlic  jtUcI'  oI'  tliis  coiKlilitvn. 

Tetanus^  (Lock  Jaw). 

This  acute  infectious  disease  is  caust'd  hy  ilio  invasion  of  a  specific 
micro-organism. 

Etiology. — Any  open  wound  on  the  surface  of  the  hody  can  be  the 
point  of  entrance  for  these  pathogenic  bacteria. 

There  are  some  parts  of  our  country  in  which  the  disease  exists  all 
tlie  year  round,  provided  the  factors  which  cause  the  same,  filth  and  dirt, 
are  brought  into  play.  A  child  infected  with  tetanus  can  transmit  the 
disease,  hence  this  should  be  borne  in  mind  while  a  case  is  under  treatment. 

Bacteriology. — Nicolaier  in  1884  found  a  specific  micro-organism  in 
the  soil  from  which  he  infected  animals  and  produced  tetanus.  He  also 
jound  this  germ  present  in  patients  affected  with  tetanus. 

In  1898  Kitasato  demonstrated  this  bacillus  in  pure  culture.  It  was 
also  found  in  infants  suffering  with  tetanus.  From  the  pure  culture 
Kitasato  and  Behring  jiroduced  an  antitoxin. 

The  toxin  generated  by  tetanus  is  a  deadly  poison.  Kitasato  found 
that  an  animal  wliicli  was  infected  and  left  alone  died  in  one  hour. 

Pathology. — Distinct  les'ons  of  tetanus  cannot  be  demonstrated  patho- 
logicalh%  An  open  wound  and  evidences  of  a  general  septic  infection  can 
usually  be  found.  Haemorrhages  of  the  brain  or  smaller  haemorrhages  in 
various  parts  of  the  body  may  exist.  If  the  umbilicus  has  been  the  point 
of  entrance,  the  wound  will  not  heal. 

Symptoms. — In  the  new-l)orn  the  first  symptom  noticed  is  the  refusal 
to  take  the  breast.  Owing  to  the  rigidity  of  the  uniscles  the  jaws  will  be 
found  stiffened  and  feel  hard  to  the  touch.  The  same  spasmodic  stiffening 
will  be  made  out  in  the  other  parts  of  the  body.  After  a  sudden  stiffening 
the  muscles  usually  relax.  Muscular  rigidity  appears  in  parox5'sms  and 
may  come  on  every  few  minutes. 

The  temperature  varies  between  101°  and  104°  F.  or  there  may  be 
hyperpyrexia  reaching  10^  °  F.     The  pulse  is  small,  feeble,  compressible,  and 
very  rapid.      Symptoins  of  malnutrition,  such  as  emaciation,  are  very  evi 
dent.      Stadtfeldt  reports  88  fatal  cases;  83  of  these  died  between  the  agi'^- 
of  six  and  ten  days.  j 

The  following  case  illustrates  tetanus  seen  in  private  practice: — 

A  female  infant  fifteen  days  old  was  seen  by  me  siifTerin}?  with  fever.  The  nurs( 
said  that  she  refused  the  breast.     The  infant  was  in  <rood  healtli  apparently  up  to  thif 


'  Owinf^  to  the  specific  efl'ect  of  tlie  tetanus  bacillus  on  the  nervous  system.  1 
have  purposely  placed  this  article  in  the  chapter  dealing  with  lesions  of  the  braii 
and  ner\'ous  system. 


EPILEPSY.  801 

time.      The  appetite  was  good,  tlie  bowels  regular,  no  gastric  disturbances  existed. 

'  On  examination  the  umbilicus  was  found  inflamed  and  suppurating.     The  temperature 
wa.s  102°  F. ;    the  pulse  IGU.      The  jaws  were  ilxed.      The  infant  had  spasms,  which 

!  grew  inure  severe  when  slie  was  lumdled.      Tlie  })o<\\   rciaxcil  fur  a  few  minutes  at  a 
time. 

TJie  treatment  consisted  in  cleansing  tlie  wound  with  strict  asepsis,  dusting 
europhen  powder  on  the  umbilicus,  and  protecting  the  same  with  a  sterile  bandage. 
The  rectum  and  colon  were  flu.S'hed  with  waim  saline  solution.  An  injection  of  5 
cubic  centimeters  of  antitetanu-s  serum  was  given  \nth  the  usual  antitoxin  sjninge. 
As  no  effect  was  evident  from  the  injection,  a  second  injection  of  5  cubic  centimeters 
was  administered  twelve  hours  later.  Symptoms  of  improvement  followed  and  tlie 
child  recovered. 

A  second  ca.se  of  tetanus  was  one  caused  by  scratcliing  an  open  wovuid  situated 
near  the  nose,  while  playing  with  a  canary  bird.  Symptoms  of  tetanus  appeared 
two  days  after  infection.  This  case  was  also  seen  in  consultation  by  Dr.  George  F. 
Shrady.  Large  quantities  of  tetanus  antitoxin  were  injected  with  no  beneficial 
result.  The  ease  ended  fatally.  In  this  case  the  infection  wa.s  traced  to  some 
canary  birds  which  were  in  the  same  room  as  that  occupied  by  the  family. 

Prognosis  and  Course. — The  duration  of  fatal  cases  is  seldom  more 
than  one  or  two  days.  Those  tending  to  recovery  nsiially  extend  from  one 
to  three  weeks. 

While -occasionally  cures  are  reported,  five  out  of  ten  seen  by  me  have 
ended  fatally.  I  have  seen  cases  both  in  this  country  and  abroad,  injected 
with  sufficient  antitoxin,  end  in  recovery. 

Treatment. — The  bromides  of  potassium  and  sodium,  chloral  hydrate, 
belladonna,  and  opium  are  among  the  anti-spasmodics  used.  It  is  essen- 
tial to  give  large  doses  or  no  effect  will  be  ])roduced.  Calabar  bean  has  been 
lauded  by  some  authors  and  can  be  given  hypodermically. 

The  literature  records  a  great  many  cases  Avhcre  the  antitoxin  was  in- 
jected directly  into  the  l)rain.  In  the  new-ljorn  baby  this  m.ethod  should  be 
used,  as  there  is  no  obstacle  to  the  introduction  of  the  needle  through  tlie 
open  fontanel. 

In  one  case  treated  by  me  the  jintitoxin  was  injected  through  the  ante- 
rior fontanel. 

Epilepsy. 

Epilepsy  is  frequently  seen  in  very  young  children.  Some  writers  state 
that  it  develops  in  children  api)roacbing  puberty.  I  have  seen  epileptic 
spasms  in  children  under  1  year  of  age. 

Etiology. — Children  whose  parents  are  drunkards  or  where  nervous 
diseases  exist  are  predisposed  to  this  condition.  According  to  Berkely.  33 
per  cent,  of  these  cases  give  a  history  of  alcoholism  in  one  parent.  Rachitic 
infants  are  frecpiently  seen  with  epileptic  seizures,  so  that  it  is  quite  pos- 
sible that  they  are  predisposed.  Children  who  have  suffered  with  convul- 
sions in  early  life  frequently  have  epilepsy  later  in  life.  This  has  led  some 
authors  to  believe  that  convulsions  and  epilepsy  are  as  cause  and  effect. 


,S02  J)1SKASKS    OF     PHK    XKR\()rS    SYSTE:\r. 

UndnuljtcMlly  many  ca?es  of  this  kind  exist.  Statistics  prove,  how- 
ever, tliat  one-lialf  of  all  eelaniptie  chihlrt'n  liave  no  further  nervous  dis- 
eases in  later  life,  llenee,  ire  iiii(,'<t  nol  ( laini  Uiat  if  an.  infant  suffers  inll 
eclampsia  it   must   necessarily  heconie  an   epileptic. 

An  injury  to  the  head,  fright,  or  sunstroke  nuiy  possibly  cause  this  di^ 
ease.  Some  authors  state  that  epileptic  convulsions  are  intimately  ass<i 
elated  with  adenoid  vegetations,  phimosis,  and  masturbation.  Foreigi 
bodies  in  the  nose,  throat,  and  ear  may  occasionally  be  predisposing  factors 
Other  writers  believe  that  menstrual  disoiders  will  ])rovoke  epilepsy. 

"The  etiology  of  idiopathic  epilepsy  is  mainly  to  be  sought  in  ale" 
holism  in  the  ])arents.  which  induces  a  defective  organization  of  the  braii 
structures  in  the  descendants.     Inherited  syphilis  is  a  less  frequent  factor 
The  signs  of  inheritance  are  chiefly  seen  in  the  de])arture  from  the  nornui 
in  the  skull   formation,  niicrocephalus.   macrocephalus,   as  well   as   asym 
metrics  of  the  skull  and  facial  hones.    Flatness  of  the  cranial  arch  is  foum 
in  a  considerable  proportion  of  e})ileptics,  particularly  among  the  males 
Signs  of  rickets  are  especially  frequent  in  epileptic  children.     Aronsohn 
in  a   study  of  h(n-edJty  among  ."iOS  epileptics,  found   a  history  of  neuro 
pathic  disease  in  the  parents  in  33  per  cent.     Females  showed  a  stronge; 
tendency  to  inherit  the  disease  than  males,  33  per  cent,  against  30  per  cent 
The  disposition  on  the  part  of  the  mother  to  transmit  epilepsy  is  greate: 
than  that  of  the  father   (39  '/._,  against  2!)  per  cent,  of  inherited  cases) 
Where  hoth  })arents  were  hereditarily  burdened,  63  per  cent,  of  the  childrei 
inherited  the  disease.     In  82  per  cent,  of  the  inherited  cases,  the  diseaS' 
began  before  the  twentieth  year  of  life.    Wildermuth,  in  145  cases  of  earl; 
epilepsy,  found  inherited  tendencies  in  49  per  cent.,  drunkenness  on  thi 
part  of  the  parents  contril)uting  nearly  one-half    (21   per  cent.)    of  th 
examples.     Traumatism  in  early  life  furnishes  a  small  number  of  case 
of  epilepsy.     Among  210   patients   assend)led   by   Wildermuth   anteccden 
injury  to  the  head  had  occurred  eight  times.     In  the  majority  of  the  trauj 
nuitic  cases,  the  seizures  followed  the  injury  within  a  few  days  or  weekfi 
seldom  after  months.     Epileptiform  seizures  and  their  sequels  are  some' 
times  found  M'here  there  has  l)een  antecedent  meningitis,  porencephalia,  o  j: 
cerebral  haemorrhage  in  infancy;    they  may  also  result  from  acute  infec; 
tious  processes,  but  in  these  instances  they  are  to  be  regarded  not  as  bci 
longing  to  true  epilepsy,  but  as  the  symptomatic  expression  of  a  eoarsf 
irritative  cerebral  lesion"   (Berkley). 

Pathology. — Gowers  states  that  the  disease  is  probably  located  in  th 
gray  matter  of  the  cortex.  Tt  should  be  regarded  as  a  muscular  spasm^  th 
result  of  the  sudden  overaction  or  discharuc  of  the  nerve  cells.^ 


^  Gowers.      Diseases  of  the  Nei-\'ous  System,  Ainer.  Ed.,  1888. 


EPILEPSY.  808 

Of  1450  cases  of  epileps}-  studied  by  this  same  writer,  13  per  cent, 
begau  during  the  first  three  years  of  life,  and  -IG  jjer  cent,  between  the 
tenth  and  twentieth  years. 

An  interesting  jioint  was  brought  out  by  Herter  and  Suiith,^  who 
studied  238  specimens  of  urine  taken  from  31  epileptics. 

They  noticed  that  in  72  of  these  observations  there  was  excessive  in- 
testinal putrefaction,  as  shown  by  the  presence  of  ethereal  sulphates  in  the 
urine  just  before  the  occurrence  of  the  spasm.  These  authors  were  war- 
ranted, therefore,  in  their  conclusion,  that  there  is  a  distinct  association 
between  the  intestinal  poisoning  and  the  epileptic  seizures.  We  can  readily 
see  that  the  treatment  of  any  case  of  epile^jsy  must  l)e  followed  along  the 
lines  just  described. 

Symptoms. — There  are  two  kinds  of  attacks  usually  met  with :  first, 
the  grand  mal;    second,  the  petit  mal. 

Grand  Mal  Form. — The  attack  may  come  on  gradually  or  it  may  be 
sudden.  Cliildren  old  enough  to  complain  frequently  have  a  warning  of 
the  attack  known  as  the  aura.  This  aura  consists  in  a  series  of  symptoms, 
such  as  a  twitch  in  the  leg  or  the  face,  constituting  a  local  sj)asm  described 
l)y  some  authors  as  a  "motor  aura."  I'hen  again  there  may  be  abnormal 
sensations,  such  as  a  t.'ngling  or  numbness  in  any  part  of  the  body,  until 
the  patient  suddenly  falls  with  the  spasm.  There  may  be  an  unusual 
tremor  or  a  shivering  sensation,  and  the  patient  may  fall  to  the  floor  with 
a  sharp  cry,  having  the  jaw  set  and  all  the  muscles  of  the  body  in  tonic 
spasm.  The  eyeballs  are  usually  rolled  upward.  After  a  few  seconds,  dur- 
ing which  the  skin  is  cyanotic,  a  second  stage  follows  in  which  there  are 
clonic  spasms.  There  may  be  involuntary  spasms  of  the  bladder  and  bowel. 
In  the  clonic  stage  the  muscles  frequently  contract  and  relax  violently. 
Not  infrequently  the  tongue  is  apt  to  be  caught  between  the  teeth  and  is 
bitten.  There  may  be  frothing  at  the  mouth.  Very  marked  rigidity  of 
the  sterno-cleido-mastoid.  The  head  may  be  thrown  I)ackward  or  it  may 
he  twisted  to  one  side.  1'he  extremities  ma}"  relax  and  then  become  rigid 
again,  and  tlie  cyanosis  gradually  disappears.  Children  usually  fall  into 
a  deep  sleep  as  though  exh.austcd  after  the  end  of  the  clonic  stage.  This 
sleep  lasts  hours  at  times.  Children  old  enough  to  describe  symptoms  will 
state  that  they  have  no  knowledge  of  what  has  ha]>pened.  They  awake  just 
as  children  do  after  a  deep  chloroform  narcosis. 

Petit  ]\fal  Form. — This  is  a  milder  type  of  the  condition  above  de- 
scribed. The  attacks,  instead  of  lasting  minutes  and  hours,  usually  last 
but  a  few  seconds.  The  child  does  not  fall,  b\it  may  sit  quietly  during  the 
seizure  until  it  passes  ofp. 

An  aura  is  absent  in   this  condition.     The  attacks  not  infrequently 


'  Xew  York  ^[edifiil  .To>irnal.  A\if?u.st  and  Septciiiber,  1892. 


804  DISEASES  OF  THE  NERVOUS  SYSTEM. 

happen  several   times  a  day.     They   may   also  occur  at  night.     In  somo 
children  we  have  hoth  varieties. 

Differential  Diagnosis. — Epilepsy  is  frequently  confounded  with  hys- 
teria. In  hysteria  there  is  partial  consciousness.  In  epilepsy  there  is  a 
loss  of  consciousness.  The  biting  of  the  tongue  and  symptoms,  such  as  the 
nocturnal  apjjearance  of  the  attacks,  will  aid  in  establishing  the  diagnosis. 
There  is  usually  a  dilatation  of  the  pupils. 

An  epileptic  may  have  an  attack  in  inopportune  places,  such  as  the 
street  or  on  a  hot  stove,  whereas  a  case  o!"  hysteria  usually  selects  a  place 
indoors,  entirely  out  of  danger. 

Prognosis  and  Course. — This  disease  does  not  follow  a  regular  course. 
The  usual  interval  between  seizures  in  the  very  beginning  may  be  months. 
Eegular  intervals  of  epileptic  attacks  may  be  every  two  or  four  weeks.  In 
some  severe  cases  seen  by  me  the  attacks  came  on  every  day.  It  is  not 
unusual  for  epileptic  seizures  to  come  at  night  only.  When  such  is  the 
case  the  diagnosis  is  very  difficult. 

The  outcome  depends  on  the  condition  of  the  patient.  A  child  may  be 
seized  with  an  attack  while  on  the  street  and  be  killed  by  an  accident.  In- 
stances are  on  record  where  epileptics  have  fallen  in  the  water  and  were 
asphyxiated  during  the  spasm.  Traumatic  epilepsy  will  occasionally  be  i 
cured  by  surgery.  Generally  speaking,  the  cases  of  epilepsy  seen  by  me  did  I 
not  do  well  with  surgical  treatment,  | 

Treatment. — A  case  of  this  kind  should  never  be  left  alone,  owing  tf  I 
the  danger  of  accident  during  the  epileptic  seizure.  If  a  cause  exists,  sucll 
as  adenoid  vegetations  or  phimosis,  the  same  should  be  radically  treated.  Ij 
have  previously  mentioned  the  results  of  Herter's  examinations  of  the  urine  ' 
thus  we  find  that  the  products  of  indigestion  are  usually  found  in  epilepsy 

Dietetic  Treatment. — Arguing  from  this  point  of  view,  the  stomaci 
and  bowels  must  not  only  be  constantly  supervised,  but  the  lightest  kind  ol! 
nutrition  that  will  yield   strength   should  be  ordered.     The  action  of  tin 
bowels  must  he  frequent.      The  slightest  constijiation  should  not  lie  pci- 
mitted. 

Cereals,   vegetables,   and    fruits,   in   fact,   the   lightest   kind    of   da  in 
products,  should  be  ordered.    ]\reat  and  similar  stimulating  nutrition  shouh 
be  enjoined.     "Water  and  liquids  should  be  freely  given.     Neither  alcoho 
tea,  nor  coffee  should  be  allowed. 

Hygienic  Treatment. — Children  so  afflicted  should  be  kept  out  of  doo 
as  much  as  possible.     They  should  not  attend  school.     They  should  ha 
cheerful  surroundings  and  avoid  all  useless  excitement.     They  should 
given  a  bath  daily  and  a  proper  amount  of  sleep. 

Drug  Treatment. — Sodium  bromide  seems  to  be  the  drug  par  exa 
Icnce  in  the  treatment  of  this  disease.  Children  can  take  as  large  if  n 
larger  doses  of  bromide  than  adults.     I  have  frequently  given  10  grains 


ACUTE    MYELITIS.  805 

bromide  of  soda  to  a  child  1  year  old,  and  repeated  the  same  several  times 
a  da}'. 

We  must  study  the  tolerance  of  every  child  by  carefully  increasing 
the  dose  until  the  physiological  effect  of  the  same  is  produced.  Seguin 
advises  giving  large  doses  early  in  the  morning,  small  doses  during  the  day, 
and  large  doses  at  night.  The  reason  for  the  large  dose  at  night  is  the  fre- 
quency with  which  the  attacks  appear  in  the  night.  Belladonna  is  advised 
by  some  authors.  Chloral  hydrate  is  frequently  useful  when  combined 
with  the  bromides.  I  sometimes  use  arsenic  alone  when  the  bromides  cause 
acne. 

Restorative  treatment  should  be  combined  with  this  anti-spasmodic 
treatment.  The  system  sbould  be  strengthened  by  giving  iron  and  strych- 
nine. The  use  of  ma't  extracts  and  codliver-oil  will  be  found  beneficial, 
licgarding  the  surgical  treatment  of  epilepsy  Sachs,  quoted  by  Holt,  says: — 

"In  a  case  due  to  a  traumatic  or  organic  lesion  an  early  operation  may 
prevent  the  development  of  cerebral  sclerosis.  If  an  early  operation  is  not 
done,  the  occurrence  of  epilepsy  is  a  warning  that  secondary  sclerosis  has 
been  established  and  an  operation  may  prevent  it  from  increasing.  Opera- 
tion must  include  the  removal  of  the  diseased  area;  here,  if  all  other  parts 
are  normal,  a  cure  nmy  result.  lender  favoral)le  conditions  a  few  cases  of 
epilepsy  may  be  cured  b}'  surgery  and  many  more  improved." 

B.  Sachs  and  A.  Gerster^  give  the  following  summary:  An  opera- 
tion is  jiermissible  in  traumatic  epile})sy  when  the  case  is  not  over  1  or 
2  years  old.  When  there  is  a  depression  of  bone,  the  operation  is  indi- 
cated at  a  later  period,  but  should  not  be  delayed.  Trephining  alone  is 
sometimes  sufficient.  If  the  disease  is  of  short  duration,  a  part  of  the 
cortex  may  be  incised.  The  complication  of  infantile  cerebral  paralysis, 
if  the  case  be  recent,  is  no  eontraindicat'on  to  the  operation.  It  must  not 
be  performed  in  epilepsy-  of  long  duration. 

Acute  Myelitis. 

This  condition  consists  in  a  diffuse  inflammation  resulting  in  destruc- 
tion of  spinal  elements  and  the  softening  of  the  cord. 

Etiology. — It  is  not  a  rare  condition,  but  is  most  frequently  seen  as  a 
complication  of  the  infectious  diseases.  Chilling  of  the  surface  of  the  body 
seems  to  favor  the  development  of  this  condition.  Some  authors  state  that 
it  follows  metallic  or  other  chemical  ])oisonings.  It  is  frequently  associated 
with  spinal  trouble,  such  as  Toft's  disease.  Injury  is  frequently  given  as 
a  cause,  hill  si/philis  is  the  most  frcqupnt  cause. 

Pathology.  —  ]\farroscopical:  The  cord  is  seen  thickened  and  sur- 
rounded by  hypera^mic  meninges.  T]\v  substance  of  the  cord  is  much 
softer  than  normal  and  sometimes  resembles  jms.     Frequently  small  ])unc- 

*  American  Journal  Medical  Science.,  October,  1896. 


806  DISEASES    OF    THE    XERVOLS    SYSTEM. 

tate  haemorrhages  and  even   larger  extravasations  of  blood   can  he  secii' 
microscopically.      In  severe  disintegration  of  the  cord,  the  microscopical 
findings  are  useless.    It  is  in  the  mildest  forms  that  pathological  changes 
can  best  be  studied.     In  the  dilated  blood-vessels  we  find  leucocytes  and 
granules  of  myelin.     Corpora  amylacea  are  frequently  seen. 

Symptoms  and  Diagnosis. — The  symptoms  depend  on  the  portion  of 
the  cord  tissue  involved,  and  on  the  severity  of  the  process.  In  syphilis  we 
have  a  slowly  developing  condition  weeks  and  months  before  myelitis 
symptoms  pointing  to  this  condition  can  be  noticed.  If  children  can 
complain  they  describe  a  sense  of  weight  in  the  legs  which  gradually 
increases  so  that  in  a  few  days  the  limbs  are  entirely  palsied.  Convulsions 
and  delirium  have  frequently  been  noted.  When  the  reflexes  are  anatom- 
ically related  to  the  affected  segments  they  disappear,  and  below  that  level 
they  are  increased ;  after  a  few  days,  if  the  cord  has  been  entirely  de- 
stroyed at  the  inflammatory  focus,  the  reflexes  are  entirely  abolished 
(Church).  "Provided  the  posterior  roots  and  meninges  are  involved,  pain 
in  the  back  and  limbs  is  a  prominent  symptom,  but  rarely  is  of  an  ex- 
cruciating character  at  the  onset.  At  the  upper  level  of  the  inflammation 
some  pain  is  the  rule,  which  gives  rise  to  a  band  or  girdle  sensation  and  a 
zone  of  hyperaesthesia  about  the  abdomen  or  chest.  This  sign,  with  the 
paralysis,  definitely  localizes  the  upper  limit  of  the  lesion,  but  if  it  be  in 
the  lower  cervical  region  this  sensation  ])asses  down  the  arms  and  is  not  so 
sharply  defined.  Les'ons  in  the  cervical  region  are  also  marked  by  impli- 
cation of  the  cilio-spinal  center,  with  consequent  dilatation  of  the  pupil. 
Continuous  priapism  is  then,  too,  a  usual  occurrence,  and  the  intercostal 
muscles  and  heart  may  be  affected.  Below  the  lesion,  and  depending  upon 
its  intensity,  there  are  variat'ons  in  sensibility  to  all  forms  of  stimulation, 
from  slight  blunting  to  tlie  usual  complete  anaesthesia.  Sensations  of 
drowsiness  and  aching  in  the  paralyzed  and  ana'sthetic  limbs  are  some- 
times inentioned  ;  and  cramps  and  drawing  up  of  tlie  limits  frequently 
occur  early,  and  later  are  the  rule.  Distinct  muscular  atrophy  related  to 
the  portion  of  the  cord  affected  takes  place,  but  in  the  trunk  it  is  not 
readily  discerniljle.  The  paralyzed  limbs  during  the  first  few  days  are 
abnormally  warm,  but  soon  present  a  sul)normal  temperature;  sluggish 
circulation  and  emaciation  ensue,  with  o'dema  of  the  feet  and  legs  if  the 
limbs  are  left  any  length  of  time  in  a  pendent  position.  If  the  lesion  is  low 
down,  the  atrophy  is  a  marked  feature  and  the  reaction  of  degeneration  is 
present.  I"^nder  the  influence  of  pressure,  1)ed-sores  form  on  prominent  por- 
tions of  the  l»o(ly  and  liiiil)s,  and  this  very  early.  In  some  cases  witbin  the 
first  week  immense  sphacelization  may  take  place  over  the  sacrum,  Avhich 
cannot  be  explained  by  pressure  and  the  moisture  from  the  urine,  but  im- 
plies a  dystrophic  condition  of  cord  origin.  Trophic  symptoms  (bed-sores) 
are  especially  liable  to  occur  when  the  lumbar  cord  is  the  seat  of  the  disease. 


I 


]\1ALF0R^L:VTI0X    OF    THE    SPiXAL    CORD.  '         gQT 

Prognosis  and  Course. — The  course  of  the  disease  is  chronic.  The 
condition  varies  but  little.  The  symptoms  get  worse  and  worse  until  death 
ends  the  trouble.  From  a  few  weeks  to  a  few  months  may  terminate  the 
disease. 

At  times  if  it  is  associated  with  or  dependent  on  Pott's  disease,  un- 
provement  may  be  exj)ected.  Sometimes  myelitis  is  caused  by  syphilis 
either  in  its  active  form  or  due  to  a  syphilitic  neoplasm.  It  is  rare  in  such 
conditions  to  effect  a  cure. 

Treatment. — If  specific  conditions  such  as  syphilis  exist,  then  anti- 
luetic  treatment  is  required.  Iodide  of  sodium  can  be  given  in  very  large 
doses,  5  to  50  grains  per  day.  The  general  indications,  such  as  attention  to 
the  stomach  and  bowels,  must  be  met  and  stimulated  if  required.  It  is  im- 
[lortant  to  feed  a  patient  in  this  condition  with  very  nutritious  food.  CoUn- 
ter-irritation  over  the  spine  is  advisable.  For  this  purpose  tincture  of  iodine 
or  mustard  will  he  useful.  I  insist  on  a1)Solute  rest  in  bed  (water  bed  if 
possible)  and  in  frequent  change  of  position. 

Chroxic  Myelitis. 

This  condition  is  usually  the  continuation  or  the  prolongation  of  acute 
softening  of  the  cord.  It  is  here  that  we  find  bed-sores  as  well  as  disturb- 
ances of  the  bladder  and  bowels. 

Treatment. — The  treatment  consists  in  what  lias  l^een  previously  ad- 
vised in  the  acute  condition.  Life  can  only  be  prolonged  by  giving  tone  to 
the  system  with  proper  food. 

Malformatiox  of  the  Spinal  Cord  (Spina  Bifida). 
The  most  frequent  malformation  seen  is  spina  bifida.  It  affects  the 
vertebral  canal  and  ends  in  a  protrusion  of  a  small  or  large  soft  tumor  filled 
with  serum.  This  serum  is  a  clear  yellowish  liquid  similar  to  eerebro-spinal 
fiuid.  We  are  indebted  to  Humphrey^  for  an  accurate  description  of  this 
lesion.  He  says:  "Spina  bifida  is  due  to  an  early  failure  in  development, 
in  most  cases  l)efore  the  cord  is  segmented  from  tbe  e])iblast:c  layer  from 
which  it  is  developed.  Hence,  it  remains  adherent  to  the  epiblastic  cov- 
ering, and  tlie  structures  which  should  l)e  formed  I)ctween  the  cord  and  the 
skin  are  developed.  For  this  reason  we  ha\e  in  the  wall  of  the  sac  a  fusion 
of  the  elements  of  the  cord,  nerves,  meninges,  vertebral  arches,  muscles,  and 
integument.  If  the  error  in  development  occurs  later,  the  cord  and  nerves 
may  be  attached  to  the  sac,  but  not  intimately  fused  with  it;  in  still  other 
cases  the  cord  does  not  enter  flic  sac  at  all.  The  malformations  may  occur 
before  the  central  canal  is  closed,  or,  if  closed,  it  may  reopen  from  the 
accumulation  of  fluid.     It  is  probable  that  the  accumulation  of  fluid  first 


'  Jvancot,  March  28,  1885. 


808 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


occurs,   and  tliiit    thit^   prevents  the   union   of   the   parts   of   the   vertebral 
arches. 

"Although  the  tumor  is  generally  associated  with  a  bifid  spine,  this  is 
not  necessarily  the  case.  The  protrusion  may  take  place  through  the  inter- 
vertebral notch  or  foramen,  or  there  may  be  a  fissure  of  the  bodies  of  the 
vertebra^,  and  an  anterior  tumor  ])rojecting  into  the  cavity  of  the  thorax, 
abdomen,  or  pelvis,  spina  bifida  occulta.  The  principal  anatomical  varieties 
are  meningocele,  meningo-myelocele,  and  syringo-inyelocele." 


Fig.  258.  — Case  of  Spina  Bifida.  Spontaneous  cure.  Male  child,  6 
years  old.  Now  suifers  with  paralysis  of  both  legs.  Well  nourished.  No 
evidence  of  hydrocephalus.      (Original.) 

The  following  case  of  spina  bifida  occurred  in  my  private  practice.  A  boy,  6 
years  old^  was  brought  to  me  with  a  history  of  having  a  very  large  growth  in  the 
lumbar  region.  The  sac  burst  spontaneously.  Since  that  time  the  boy  has  a  double 
paralysis,  and  also  sutlers  with  incontinence  of  urine  and  fsjeces.  He  was  broiight  to 
me  for  the  treatment  of  the  paralysis.  The  general  condition  was  good  and  he 
appeared  well  nourished.     There  was  no  evidence  of  hydrocephalus. 

Treatment. — The  treatment  of  spina  l)ifi(la  is  surgical.  I  have  seen 
a  number  of  successful  cases. 


Hereditary  Ataxy  (Friedreich's  Disease).^ 

This  condition  is  caused  by  a  degeneration  of  the  posterior  columns 
of  tlie  spinal  cord.  As  a  rule  several  members  of  the  same  family  are 
affected. 


^I   am   indebted    to   Williams's   excellent   monogra])h   for   some   points   in   ihis 
article. 


INFANTILE    SPIKAL    PAKALYSIS.  809 

Etiology. — This  disease  is  usually  seen  at  or  about  the  period  of 
puberty.  Measles,  scarlet  fever,  or  any  other  acute  infectious  disease  may 
precede  the  development  of  this  condition. 

Pathology. — The  lesions  seen  are:  "Sclerosis  in  the  posterior  columns 
(columns  of  Goll  in  their  whole  extent,  and  columns  of  Burdach  in  their 
upper  part),  in  the  direct  cerebellar  tract  extending  laterally  into  the  column 
of  Gowers,  in  the  lateral  columns  (crossed  pyramidal  tract),  in  the  gray 
matter  (columns  of  Clarke,  and  posterior  horns).  In  some  cases  dilatation 
of  the  central  canal  has  been  observed." 

Symptoms  and  Diagnosis. — The  motor  system  shows  the  most  charac- 
teristic symptoms.  The  patient  stands  Avith  the  feet  far  apart.  The  body 
sways  and  there  is  an  unsteadiness  while  trying  to  maintain  the  equilibrium. 
The  gait  resembles  that  of  an  alcoholic  intoxication.  A  tremor  of  the 
hands  and  head  and  choreiform  movements  affect  the  same  parts.  Paralysis 
and  emaciation  may  be  present.  The  tendon  reflexes  are  absent  as  a  rule, 
but  their  presence  does  not  speak  against  the  diagnosis  in  the  early  stage  of 
the  disease.  The  eyes  show  nystagmus.  There  is  no  optic  atrophy.  There 
is  vertigo.  The  speech  is  slow.  The  intellect  seems  impaired.  There  is  a 
peculiar  clubbing  of  the  feet.  The  foot  is  short.  The  toes  are  over- 
extended, the  instep  high  and  hollow.  The  Babinski  phenomena  or  hyper- 
extension  of  the  big  toe  may  be  the  first  symptom  of  this  condition. 

The  prognosis  is  grave.     The  disease  lasts  years. 

Treatment. — The  disease  runs  its  course,  although  electricity  and 
j-cstorative  treatment  plus  massage  may  be  tried.  The  disease  usually  ends 
fatally. 

IXFAXTILE   SpIXAL    PaRALYSIS    (POLIOMYELITLS) . 

This  disease  is  characterized  by  a  sudden  onset  of  fever,  then  paralysis, 
usually  followed  by  muscular  atrophy  and  imperfect  l)one  development, 
sometimes  l-y  deformity. 

Etiology. — Tl'.e  majority  of  cases  occur  before  the  tenth  year.  Some 
authors  state  that  three-fifths  are  seen  before  the  fourth  year.  The  most 
susceptil)le  period  seems  to  be  during  the  last  six  months  of  the  first  year. 
The  majority  of  cases  occur  in  summer  (Sachs). 

Most  cases  occurring  in  hot  weather  begin  with  fever,  diarrhoea,  and 
vomiting.  Tliere  seems  to  bo  reason  to  believe  tliat  the  bacterial  infection 
in  the  intestine  generates  a  toxaemia  which  may  be  an  etiological  factor. 

Pathology. — We  are  indebted  to  Provost  and  Uoldscheider  for  a  com- 
l)lete  study  of  the  pathology  of  tliis  condition.  Tlio  latter  l)elieves  that  "a 
condition  of  irritation  is  ])rcsent  in  the  walls  oL'  the  blood-vessels  of  the 
cord  leading  to  their  dilatation  and  to  the  proliferation  of  their  endothelial 
elements.  Tiater  degenerative  changes  occur  in  the  ganglion  cells,  as  well 
:i>^  in  the  new  fibers  appearing  in  the  vicinity  of  the  altered  blood-vessels." 


810 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


The  clinical  data  show  this  to  be  due  to  au  invasiou  of  bacteria,  although, 
it  has  not  yet  been  proven.  The  fact  that  the  disease  appears  in  epidemics 
points  to  the  possibility  of  bacterial  invasion.  The  intlanimatory  process  is 
limited  to  the  anterior  horns  or  extends  to  the  medulla  and  pons.  The 
inflammatory  process  is  interstitial,  not  parenchymatous.  "The  muscles 
become  atrophied.  The  fibers  diminish  in  size,  possibly  disappearing,  their 
places  being  tilled  by  adipose  tissue." 


Fig.  251>. — Poliomyelitis.  Sclerosis  ami  eieatricial  atrophy  of  the  left 
anterior  horn  of  the  fourth  cervical  nerve  after  acute  anterior  poliomyelitis. 
(a)  Normal  anterior  horn  with  ganglion  cells,  (bj  atrophic  anterior  horn. 
(Ziegler.) 

Table  No.  102. 


ACT'TE    SPINAL    PALSY. 

Onset  sudden,  with  fever,  coma,  and 
convulsions.  ( 'onvulsions  rarely  re- 
peated after  first  few  days. 

Paralysis  flaccid,  associated  with 
atrophy.  Marked  trophic  changes.  De- 
formity without  contractures. 

Paralysis  widely  distributed,  possibly 
involving  all  extremities,  or  narrowly 
limited  to  one  member  or  even  a  single 
group  of  muscles. 

Electric  reactions  altered  (IJ.  D.). 

Deep  reflexes   diminished  or  lost. 

Intellect  never  j)ennanently  involved; 
no  epilepsy. 


ACUTE   CEREBRAL  PALSY. 

Onset  sudden,  with  fever,  coma,  and 
convulsions.  Convulsions  apt  to  be  re- 
peatetl. 

Paralysis  spastic,  no  atrophy,  no 
markeil  trophic  changes.  Associated 
with  rigidity  and  contractures. 

Paralysis  generally  hsemiplegic,  some- 
times diplegic  or  paraplegic.  Mono- 
plegia rare. 

Electric  reaction  nonnal. 

Deep  reflexes  exaggerated. 

Intellect  often  involved;  epilepsy  fre- 
quent (Sachs). 


Symptoms. — Acute  ])oliomy('litis  usually  appears  as  any  other  infec- 
tious disease.     Children  usuallv  have  fever  reaching  102°  or  103°  F.,  fol- 


I 


INFANTILE    SPIXAL    PARALYSIS. 


811 


lowed  ])}'  a  sudden  paralysis;  sometimes  vomiting  and  eonvulsions  mav 
also  be  present.  The  reflexes  are  greatly  diminished  or  entirely  absent. 
The  emaciation  occurs  very  early  and  tlie  part  affected  is  limp.  The  nms- 
cles  lose  their  tone  and  are  soft  and  fial)l)y.  The  surface  temperature  is 
cold.  Sliortening  takes  place.  The  electric  reaction  of  the  paralyzed  mus- 
cles and  nerves  shows  "the  reaction  of  degeneration."  the  anodal  closure 
contraction  l)eing  equal  to  or  greater  than  the  cathodal  closure  contraction. 


Fig.  260. — Infantile  Paralysis,  with  Atrophy  Fig.  261.— Infantile  Paralysis,  with  Atrophy 

and  impaired  Growth  of  the  Right  Leg,  and  of  the  Right  Leg.     The  curvature  of  the  spine 

Drop-foot;  Four  Years  After  the  Onset.    Note  is  secondary  to  the  shortening  of  the  leg.  (Case 

atrophy  on  affected  side.     (Case  of  Dr.  M.  Allan  of  Dr.  M.  Allan  Starr.) 
.Starr.) 

.\ccording  to  Sachs  the  reaction  to  the  faradic  current  is  lost  at  once,  but 
lo  galvanism  it  remains  or  is  increased  for  some  time  and  then  is  lost, 
except  that  it  may  a])])ear  to  very  strong  currents.  'I'hcrc  may  be  tender- 
ness along  the  affected  nerve  and  pain  in  the  muscles  during  the  acute 
stage.  The  bladder  and  rectum  are  usually  not  involved.  The  brain  is 
not  affected,  so  that  this  condition  per  se  does  not  give  rise  to  mental  de- 
rangement. 


812  DISEASES    UF    THE    NERVOUS    SYSTEM. 

Diagnosis. — This  disease  usually  follows  fever.  At  times  it  is  a  one 
day's  fever  followed  by  paralysis.  There  is  "a  stationary  sta-ge  lasting  one 
to  six  weeks.  Then  a  period  of  improvement"  lasting  about  six  to  twelve 
months,  and  lastly,  "a  stage  of  permanent  disability,"  lasting  throughout 
life. 

The  initial  fever  is  sometimes  follow^ed  by  pain  in  the  limbs  and  the 
condition  mistaken  for  rheumatism.  Jn  no  ulhcr  disease  is  the  response  to 
the  faradic  current  absent  as  early  as  in,  this  condition.  In  diphtheritic 
palsy  the  jjrevious  history  Avill  assist  in  clearing  up  the  doubtful  diagnosis. 
Atrophy  of  the  muscles  occurs  verv  early  and  is  an  important  diagnostic 
guide. 

Prognosis.- — It  is  ditticult  to  state  what  will  be  the  outcome  of  a  ease 
of  this  kind.  I  have  seen  some  very  severe  cases  entirely  recover.  The 
severity  of  the  I^cginning  of  an  attack  is  no  guide  as  to  its  outcome.  Some 
mild  cases  may  leave  permanent  deformities;  as  a  rule,  however,  some 
muscles  remain  ])ermanently  j^aralyzed.  'J'he  reaction  of  the  Jimscles  with 
the  faradic  current  should  be  the  guide  in  estimating  the  outcome  of  any 
ease. 

The  following  case  will  illustrate  this  condition  as  seen  by  me  at  the 
children's  department  of  a  large  outdoor  service: — 

Baby  Romeo,  eleven  months  old,  male  infant,  was  referred  to  me  by  Dr.  E.  D. 
Lederman.      The  child  had  measles   when   six  months  old.      This  was   followed  by  , 
bronchitis,     ^^'as  breast-fed  three  months  and  since  then  ha.s  received  equal  parts  of 
cows'  milk  and  water.      Dentition  has  been  normal.      He  has  six  teeth.      Has  had  i 
an  occasional  dyspeptic  attack.      The  mother  states,  that  about  four  months  ago 
the   child   had   fever  lasting    one   day;     on    the   following   morning   the   legs    we.c 
paralyzed.      This  paralysis  gradually  improved  and  to-day  is  confined  to  the  right 
side  only.      Tliere  is  a  distinct  anaesthesia  over  the  foot,   which  is  gi-adiially  le-- 
toward  the   thigh.     The  patellar  reflex  is  absent   on  the  right  side.     There  is   no  , 
ankle  clonus.     The  plantar  reflex  is  very  slightly  present.      The  foot  is  very  cold,  jl 
there  is  marked  atrophy  of  the  limb  noticeable.     A  haemic  murmur  is  heard  with  the 
first   heart   sound   and   the   same  is   also  heard   in   the  vessels   of   the   neck.      Tlic 
diagnosis  of  poliomyelitis  was  made.     Massage  and  galvanic  electricity  were  ordered. 
Strychnine,  V,„o  grain,  also  baths  consisting  of  250  grams  ferri  sulphas,  crude,  every 
third  night  followed  by  brisk  friction  was  prescribed.     An  antiscorbutic  diet  was  also 
prescribed. 

Treatment. — The  strictest  attention  should  be  given  to  the  hygienic 
surroundings  of  the  patient.  A  tepid  sponge  bath  should  be  ordered  every 
day,  the  water  containing  some  sea  salt.  This  l)ath  should  be  followed  by 
massage  and  passive  movements.  A  very  gentle  galvanic  current  should  be 
used.  It  should  be  strong  enough  to  produce  mtiscular  contraction,  will) 
due  respect  to  the  child's  feelings.  TTarsh  manipulation  or  strong  current- 
of  electricity  should  be  avoided. 

Next  in  importance  is  tonic  treatment;  for  this  purpose  iron,  cod- 
liver-oil,  or  maltine  can  l)e  given  several  times  a  day.     Large  quantities  of 


INFANTILE    SriNAL    PARALYSIS. 


813 


^  butter  and  cream,  and  all  dairy  products  are  valuable  restoratives.  Stryeli- 
uine  is  very  valuable,  but  should  not  be  given  until  the  acute  condition  is 
over. 

It  is  self-understood  that  massage  to  be  eli'ectual  must  be  given  by  a 
trained  nurse  or  one  skilled  in  the  art.  L'ubbiug  the  all'ected  limbs  is  use- 
less compared  with  proper  massage. 

Electricity  should  Ijc  cautiously  administered  and  its  effect  carefully 
noted ;  under  no  consideration  should  we  permit  the  family  to  get  a  bat- 
terv  and  apply  electricity  at  random. 


Front  View.  Side  ^'i(■\v. 

Fig.  2(}2. — Infantile  Paralysis.     Note  drop-foot  and  drop-wrist.^ 

Massage  properly  used  can  sometimes  ])revent  the  cDiiti'actions  and 
deformities  that  frequently  are  associated  with  this  form  of  paralysis. 
Orthojimlic  ireatment  should  never  be  neglected  in  these  cases.  The  well- 
known  results  following  a  tenotomy  should  be  borne  in  mind.  The  intelli- 
gent physician  Avill  remember  that  systemic  conditions,  such  as  sy])hilis, 
tuberculosis,  or  rickets,  require  special  treatment,  in  addition  to  the  treat- 
ment outlined   above.      I  have  seen   splendid  results    follow   orthopaxlic 


*I  am  inde])tcd  to  Dr.  Dexter  Ashlev  for  llio  nhovc  illustrations. 


814  DISEASES    OF    THE    NERVOUS    SYSTEM. 

ireatment,  and  the  reverse  is  true  when  ehihlrt'n  are  neglected  and  left  to 
Nature. 

A.  13.,  boy,  7  years  old.  Anterior  poliomyelitis  at,  1  year  of  age.  INIother 
says  the  limb  was  quite  useless  for  a  long  time.  Became  very  much  deformed  by 
contractions.  lias  been  treateil  by  massage  and  electricity.  Examination:  Kiglit 
limb  abducted  10°,  Hexed  to  120°;  knee  Hexed  to  170°.  Eoot  in  position  of  slight 
caleaneo-cavus;  marked  atrophy,  the  right  limb  being  22  V2  inches  and  the  left  limb 
24  inches  long;  muscles  in  evidence  at  the  thigh;  tensor  vagina  femoris  much  con- 
tracted, with  which  he  abducts  and  flexes  the  leg;  a  j)ortion  of  the  abductor  longus 
and  gi-acilis  intact  but  weak,  hamstrings  weak  but  holding  the  knee  in  contraction; 
leg  muscles,  extensor  longus  digitorum  and  peroneii. 

Treatment  suggested,  tenotomy  of  hip  contraction  under  the  anterior  superior 
spine,  stretching  of  knee  contracture,  applying  plaster  of  Paris  until  all  tendency  to 
assume  deformity  is  overcome,  when  a  brace  will  be  applied. 

Hydkocepiialus. 

This  is  an  aeeumnlation  of  serum  in  the  head. 

External  lliidrocephalu^.- — When  the  etfusion  is  betw^een  the  dura 
mater  and  the  pia. 

Internal  Ilydrocephalm. — When  the  lesion  is  in  the  ventricles  of  the 
hrain.     The  latter  condition  is  most  commonly  seen. 

Acute  IIvDnocErHALUS. 

This  condition  usually  follows  basilar  meningitis.  In  acute  hydro- 
cephalus the  effusion  is  not  large.  Some  authors  state  that  no  more  than 
three  or  four  ounces  of  serum  are  present. 

Chronic  Ixternal  Hydrocephalus   (Water  on  the  Brain). 

This  condition  nnist  not  l)e  confounded  with  tubercular  meningitis. 

Etiology. — The  cause  of  primary  or  secondary  internal  hydroce])halus 
is  very  difficult  to  describe.  In  some  instances  syphilis  has  been  given  as 
the  causative  factar.  An  interesting  paper  lias  appeared  by  D'Astros^ 
who  describes  12  cases  in  which  hydroce])halus  was  associated  with  syphi- 
litic lesions,  so  that  the  condition  was  congenital.  Ky  some,  chronic  hy- 
drocephalus is  believed  to  be  due  to  tuberculosis. 

Pathology.- — "The  changes  in  the  brain  result  from  the  gradual  accu- 
nmlation  of  fluid  in  the  ventricles.  The  septum  lucidum  is  usually  broken 
down,  and  all  the  avenues  of  communication  between  the  ventricular  cav- 
ities are  greatly  enlarged.  The  continuous  distention  results  in  a  gradual 
thinning  of  the  brain  substance  which  forms  the  ventricular  w^alls;  often 
these  are  found  only  one-fourth  of  an  inch  in  thickness,  or  even  Iqss  than 
this,  the  cortex  being  a  mere  shell." 


'■Revue  Mensuelle  des  Maladies  de  1'  Enfanco,  Chapter  IX,  pp.  481  and  543. 


I 


CHRO^'IC  INTERNAL  TIYnROCEPHALUS. 


Slo 


The  brain  ap})ears  anaMiiie,  so  that  the  gray  and  wliito  sul)stances  re- 
semble each  otlier.  The  bones  of  the  skull  show  the  lesions  very  plainly. 
The  sutures  are  separated  in  some  cases.  Where  premature  ossification  has 
taken  place,  the  head  instead  of  being  very  large,  is  very  small.  This  is 
called  a  microcephalic  condition.  Sometimes  spina  Ijifida  is  associated  with 
this  condition. 

Symptoms. — The  iirst  symptoms  that  attract  attention  are,  that  the 
head  is  increasing  in  size;  that  it  seems  very  heavy;  that  the  child  appears 
stupid ;    that  it  does  not  notice  things,  but  stares  continuously.     The  fore- 


Fig.    263. — Hydrocephalic    calvaiiiiiii     (or    skull-cap),    widely    f^aping 
fontanels   and    sutures.      One-half   natural    size.      ( Langerhans.) 


head  is  very  liigh,  the  fontanel  distended  and  bulging.  On  palpating,  the 
soft  fluctuating  liquid  can  be  felt.  The  sutures  are  very  wide  apart.  The 
pupils  are  usually  enlarged,  sometimes  contracted.  Convulsions  are  fre- 
(jucntiy  ])rescnt.     "While  the  head  enlarges  the  body  emaciates. 

Prognosis  and  Course.— This  disease  usually  terminates  fatally  about 
the  seventh  year.  Tn  rare  instances  the  condition  may  extend  through  life 
with  impaired  mental  faculties  due  lo  the  brain  trouble.  Cases  that  have 
been   n'])orle(l  cured  should   l»c  viewed  with  suspicion. 

Treatment. — Aspiration  has  been  tried  by  many,  with  no  apparent 
benefit.  I  have  never  seen  a  good  result  follow  the  aspiraiion  of  tlie 
liquid,  because  the  fluid  returns  very  rapidly,  so  that  nothing  is  gained  by 
the  operation. 


SIC) 


DISEASES  (W  TIIK  NKin'OUS  SYSTE:\r. 


Fig.  2(i4. — Case  of  (  liroiiic  Internal  Hydrocephalus.  Note  the  position 
of  the  eyes  and  the  glohular  shape  of  the  head.  As))iration  of  the  ventricles 
every  week  gave  50  to  (iO  cubic  centimeters  of  a  perfectly  clear  lluid. 
(Original.) 


Fig.  265. — Front  view  of   same  case.     Note  position  of  eyes  and   ears. 
This  is  a  characteristic  expression  of  hydrocephalus.      (Original.) 


KXCEPHALOCELE.  8I7 

Blistering,  counter-irritation,  strapping,  and  lumbar  puncture  have 
been  tried  i)y  uie  with  no  apparent  success.  Iodoform  collodion  has  l)een 
recommended  by  some. 

In  a  case  seen  in  consultation  witli  Dr.  L.  Harris,  of  this  city,  convulsions  were 
relieved  by   lumbar  puncture. 

Mercurial  inunctions  and  large  doses  of  iodide  have  been  trie(L  If 
syphilis  is  the  cause,  then  some  benefit  may  be  expected  fi'om  specific 
treatment. 


Fig.  266. — Enoephalocole.  Infant  1  day  old.  admitted  to  my  hospital 
service,  having  a  globular  tumor  in  the  occipital  region  of  tlie  head.  The 
tumor  measured  8  V2  centimeters  from  above  downward,  and  8  V4  centi- 
meters from  side  to  side.  The  autopsy  was  peifoiMued  by  Dr.  .John  Larkin. 
(Original.) 

Menix<:oci;lk. 

When  there  is  defective  ossification  in  the  liones  of  the  skull  and  some 
])art  of  the  mend)ranos  of  the  brain  protrudes,  it  is  called  a  meningocele. 
Some  writers  believe  it  is  caused  by  an  intra-uterine  hydroce])halus.  These 
tiiniors  geiu'rally  contain  cerebro-s])inal  fluid  in  the  bag  of  membrane. 
Wlicn  pressure  is  exerted  over  the  swelling,  the  li(|uid  will  be  emi)tie(l  into 
the  biain.  Sonu>times  cerebral  synijitoms  will  result  fi'DUi  this  mani- 
festation. 

E\ri:p[i.\i.orKT.K   (rEiMT.UAT.  TTi:i{XIa). 

In  this  condition  there  is  a  ])rotrusion  of  the  brain  substance  in  addi- 
lion  to  the  membrane.     This  protrusion  takes  place  through  the  frontal  and 

52 


8X8  DISEASES  OF  Till-:  XKRVOIS  SYSTEM. 

occipital  bones.  It  is  usually  a  congou ital  (leforuiity.  If  the  tumor  con- 
tains a  portion  of  a  dilated  ventricle  and  is  lilled  with  cerebro-spinal  flui<l, 
it  is  called  a  hvdro-encephalocele  or  hydro-cncj'phalo-nieningocele. 

A  case  of  this  kind  was  seen  hy  iiic  some  time  u'^o  in  whicli  llic  tumor  piotriuleil 
tlirouf^li  tlif  oiripita!  bone.  It  was  a  confii-nital  ch'formity.  Distinct  {uilsation  could 
be  felt.  Tlie  tumor  increased  in  size  wlien  (lie  cliild  cried.  Convulsions  resulted  from 
forcil)ly   ])usliin<j;  the   t\)mor   into  tlie   cranial   cavity. 

Treatment. — Tlic  injection  of  1  dvacluu  of  Morton's  fluid  after  asjiira- 
tion  of  souie  of  the  ii(|iiid  contents  may  he  tried.     ]Morton"s  fluid: — 

B   Kali   iodide 30  grains 

Iodine   |)uro    10  grains 

Glycerine 1   ounce 

'S\.     Inject   1    draclim   after   e  ich   asjiiration. 

]f  no  iinprovciiicut  is  unfed  after  snuie  time,  surgical  treatment  should 
be  tried, 

Cyclops. 

This  is  a  very  rare  condition  and  consists  of  the  child  having  hut  one 
orbit,  whicli  is  sifuafe(l  in  tlie  middh'  of  the  forehead  at  the  root  of  the 
nose. 

Porencephaly'. 

This  consists  usually  of  a  defective  develo]iment,  leaving  a  hole  in  the 
hraiu.  Tt  is  a  congenital  disease  and  nuiy  be  located  in  any  portion  of'the 
brain. 


CHAPTER  IV. 
TUBERCULAR  MENINGITIS   (BASILAR  MENINGITIS). 

This  is  usually  a  secondary  condition.  It  is  not  a  prinuiry  disease  of 
the  meninges.  In  infants,  tubercular  meningitis  usually  follo^ys  bone  tu- 
berculosis, tuberculosis  of  the  lymph  nodes  or  joints,  and  not  infrequently 
a  tubercular  otitis  may  extend  and  inyohe  the  meninges. 

Etiology. — The  association  of  adenoid  vegetation  and  the  probable 
entrance  of  the  tubercle  bacillus  through  the  lymph  channels  of  the  neck 
is  the  most  probable  means  of  infection.^  (See  article  on  "Acute  Tubercu- 
losis.") 

Bacteriology. — There  is  no  question  about  the  association  of  the 
tubercle  bacillus  with  this  infection.  It  can  be  found  in  the  spinal  fluid 
withdrawn  l)y  a  lumbar  puncture.  Other  jiathogenic  bacteria  may  also  be 
found.  In  one  case  reported  by  me  we  found  the  diplococcus  intracellularis 
in  addition  to  the  tubercle  bacillus. 

Pathology.^ — The  chief  pathological  condition  is  a  growth  of  miliary 
tubercles.  Associated  with  these  we  frequently  find  tubercular  nodules  of 
yariable  size,  and  in  almost  eyery  case  they  are  the  products  of  ordinary 
inflammation  of  the  pia  mater — lymph  or  pus — together  with  an  accumu- 
lation of  fluid  in  the  lateral  ventricles  of  the  brain.  Holt  sa3's:  "Frequently 
there  are  tubercles  in  the  pia  mater  of  the  upper  portion  of  the  cord.  The 
iniliary  tubercles  appear  as  small  gray  or  white  granules,  situated  along  the 
vessels  of  the  pia  mater.  When  few  in  number  they  are  usually  located  at 
the  base,  especially  along  the  Sylvian  fissures  and  in  the  interpeduncular 
space.  When  numerous,  they  are  most  abundant  at  the  base,  but  are  also 
seen  scattered  over  the  convexity  in  small  groups.  In  about  half  of  my 
autopsies  they  have  been  limited  to  the  base,  and,  in  no  case  were  they  seen 
exclusively  at  the  convexity.  Tubercles  are  often  found  in  the  choroid  coat 
of  the  eye.  The  amount  of  lymph  and  pus  present  is  rarely  great,  and 
never  equal  to  that  seen  in  simple  acute  meningitis.  It  is  often  a  matter 
of  surprise  at  autopsies  to  find  the  lesions  so  few,  after  very  marked  symp- 
toms. The  inflammatory  products  are  most  abundant  at  the  base.  In  addi- 
tion to  the  patches  of  greenish-yellow  lymph,  there  are  adhesions  between 
the  lobes  of  the  brain  and  thickening  of  the  pia.  In  cases  which  have  lasted 
for  several  weeks,  the  pia  mater  in  ])lnc('s  is  often  very  much  thickened. 


^This  view  is  maintained  hv  W.  Krcudcntlial,  of  New  York. 

(819) 


820 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


owing  to  coll  infiltralioii  and  the  ])n>(]iuti()n  ol'  new  connective  tissue,  ami 
it  is  studded  with  iiiiliary  tuhercles,  sonietiiiics  with  small  _yell<nv  tuhei'- 
culous  nodules;  rre(]uently  there  is  arteritis,  which  is  sonictiines  obliterat- 
ing. 

"In  the  most  acute  cases  the  brain  substance  immediately  beneath  thr 
pia  is  intensely  congested,  slightly  softened,  and  shows  under  the  micro- 
scope a  superficial  encephalitis.  The  lateral  ventricles  are  usually  distended 
with  clear  serum,  sometimes  with   serum   containinii'  flocculi   oi'   lym])h  or 


Fig.  267. — Tiil)fMciiI()iis  S])inal  ^roningitis.  Longitudinal  Section  of 
Spinal  {'old  and  Posterior  Roots,  (a)  Spinal  cord;  (h)  pia  mater;  (c) 
snbaraelinoidal  space;  {(I)  arachnoid:  (e)  posterior  roots,  cellular  infiltra- 
tion and  containing  isolated  swollen  axis  cylinders ;  (f)  vessel  with  cellular 
infiltration  and  proliferated  wall;  (g)  cellular  exudate  in  subarachnoidal 
space;    (/)  swollen  axis  cylinder.     X45.     (Ziegler.) 

pus;  the  amount  present  varies  from  one  to  four  ounces  in  each  ventricle, 
being  always  greater  in  the  subacute  cases.  The  walls  of  the  ventricles  may 
be  softened.  The  distention  of  the  ventricles  leads  to  flattening  of  the 
convolutions  from  pressure  against  the  skull,  to  hulging  of  the  fontanel, 
and  sometimes  to  separation  of  the  sutures,  if  thev  are  not  completely  ossi- 
fied." 


TUBERCULAR    IME^'INGITIS.  821 

Tuberc-ulous  nodules  varying  in  size  from  a  small  pea  to  a  walnut  are 
frequently  seen  associated  with  meningitis  in  older  children,  but  not  so 
often  in  infants.  These  nodules  may  be*  connected  with  the  meninges,  or 
they  may  be  situated  within  the  brain  substance,  usually  in  the  cerebellum. 
The  larger  ones  are  classed  as  brain  tumors.  Inflammatory  j^roducts  are 
rarely  found  in  the  spinal  canal. 

Course. — The  course  of  tubercular  meningitis  is  from  three  to  ten 
days,  although  the  symptoms  may  last  from  four  to  eight  weeks,  or  even 
longer. 

Child  B.  W.,  5  years  old.  Father  a  phj'sit-ian  and  healthy.  ^Mother  healthy. 
Had  just  returned  from  the  country  in  apparent  good  health.  Was  sent  to  school 
and  seemed  bright  mentally  and  physically.  Was  a  well-nourished  child.  Had 
had  no  previous  illness  excepting  a  disordered  stomach.  The  first  symptom  of  her 
present  illness  was  headache.  Had  a  coated  tongue,  loss  of  appetite  and  a  slight  rise 
of  temperature,  from  100°  to  101°  F.  The  temperature  was  very  characteristic.  (See 
chart.)  The  parents  suspected  a  slight  dyspeptic  attack  and  gave  her  a  laxative. 
Her  diet  was  also  corrected.  In  spite  of  cleansing  the  stomach  and  bowels,  the 
headache  persisted  and  reached  such  an  acute  stage  that  the  child  cried  and  moaned 
continuously,  and  did  not  sleep.  When  I  first  saw  the  case  the  symptoms  of  an 
acute  gastric  catarrh  were  so  evident  that  nothing  further  was  suspected.  The 
headache  persisted  in  spite  of  bromides.  The  child  complained  of  ringing  in  the 
ears.  Had  twitchings  of  the  arms  and  legs.  The  bowels  assumed  a  normal  color 
and  consistency.  An  examination  of  the  eyes  with  the  ophthalmoscope  was  first 
made  by  Dr.  H.  Jarecky  and  later  by  Dr.  Henry  S.  Oppenheimer,  who  found  vision 
good,  no  choked  disk — engorgement  of  veins  only — slight  reaction  of  pupils.  No 
evidence  of  tubercular  disea.se  was  found.  In  the  beginning  of  this  illness  the 
symptoms  of  headache  were  very  prominent.  The  child  appeared  quite  rational  and 
the  diagnosis  of  supra-orbital  neuralgia  was  made.  Dr.  George  W.  Jacoby,  who  saw 
the  case  at  my  request,  early  in  the  disease  did  not  believe  that  we  were  dealing 
with  meningitis.  Later  on,  however,  the  symptoms  were  positive.  Dr.  Abraham 
Jacobi,  who  saw  this  case  later  in  consultation,  diagnosed  meningitis.  At  his 
suggestion  leeches  Avere  applied  and  they  afforded  quite  some  relief.  The  head- 
ache reappeared  Avith  renewed  vigor  and  remained  incessant  throughout  the 
period  of  illness.  Owing  to  the  continued  pain  it  was  decided  to  relieve  the  intra- 
cranial pressure  by  lumbar  puncture.  I  aspirated  45  cubic  centimeters  of  clear  spinal 
fluid,  whicli  was  sent  to  Dr.  Billings,  of  the  New  York  Health  Department,  for 
examination.  He  rejiorted  the  presence  of  the  tubercle  bacillus  and  the  diplococcus. 
Dr.  B.  Sachs  confirmed  the  diagnosis  of  tubercular  meningitis. 

Strabismus  was  also  present.  There  was  marked  facial  paralysis.  Nausea  and 
vomiting  occurred.  Tliere  were  .spasms  and  twitchings,  also  a  ha^miple^ic  paralysis. 
There  was  also  a  unilateral  flush  on  the  cheek  and  other  well-marked  evidences  of 
vasomotor  disturbances.  The  child  was  either  so])orose,  in  a  semi-stupor,  or  crying 
and  screaming  witli  i)ain  in  the  head.  A  distinct  red  streak  remained  when  the  skin 
was  stroke<l  willi  the  finger  nail,  the  so-called  tache  cerebrale.  The  Babinski  reflex 
was  also  ])r(scn1.  There  was  spastic  rigidily  of  the  entire  body.  The  eyes  were 
half  open.  Respiration  was  labored,  at  fime.s — Cheyne-Stokes  respiration.  Tlie 
Itulse  was  small  and  compressible  and  varied  between  80  and  160.  The  child  died  of 
extreme  exhaustion  and  inanition,  after  suffering  about  ten  days  of  terrible  agony. 


822 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


Symptoms  and  Diagnosis. — A'ery  irregular  symptoms  show  themsdve 
in  this  condition.     The  clinical  picture  varies  in  each  and  every  case.     l" 
have  never  seen  two  cases  that  showed  exactly  the  same  symptoms.     Symp- 
toms of  malnutrition,  such  as  emaciation  and  general  weakness,  are  very 


Fig.  208. — C'a.se  of  Tuberculous  ]\rptiin^itis,  well  marked,  ending  fatally. 

(Original.) 

evident.  A'omiting,  projectile  in  cliaracier  witliout  nausea,  is  a  common 
symptom.  The  temperature  is  slightly  raised  in  tlie  beginning,  but  after 
the  first  week  it  usually  rises  from  100°  to  103°  F.,  or  even  higher.  The 
pulse  which  sometimes  is  accelerated  is  more  often  slower  than  normal. 


TUBERCULAR    MENINGITIS.  823 

Sometimes  it  is  compressible,  and  may  vary  between  eighty  and  one  hun- 
dred and  sixty  (80-160)  beats  per  minute.  The  respirations  are  increased 
and  irregular  in  character,  labored  and  sighing,  or  frequently  Cheyne- 
Stokes  in  character. 

Taclie  Cerehrale. — The  tache  cerebrale  is  frequently  present.  This  is 
produced  by  drawing  the  finger-nail  quickly  over  the  skin  of  the  abdomen, 
arm,  or  leg,  when  a  sharp  bright  mark  remains  for  several  minutes. 

Some  s}anptoms  come  on  very  slowly.  Intense  headache  is  complained 
of  and  is  usually  supra-orbital  in  character.  In  tbe  case  referred  to  in  this 
chapter  the  symptoms  were  masked  for  a  number  of  days.  The  eyes  usually 
show  tubercles  in  the  choroid.  In  the  case  reported  here,  although  the  eyes 
were  examined  by  two  competent  oculists,  no  evidence  of  disease  could  be 
found.  Strabismus  as  well  as  facial  pajalysis  are  frequently  seen  as  evi- 
dence of  paralysis.     Twitchings  are  frequently  noticed. 

The  Bahinsl-i  reflex  is  very  often  present. 

The  child  sleeps  with  its  eyes  half  open.  There  is  marked  evidence 
of  vasomotor  disturbance,  such  as  unilateral  flushes,  and  spastic  rigidity  of 
the  entire  body  is  repeatedly  seen. 

Lumbar  puncture  will  usually  show  a  clear  eerebro-spinal  fluid.  In 
this  fluid  the  tubercle  bacilli  can  be  located.  In  some  cases  other  pathogenic 
bacteria  ;    for  example,  the  streptococcus  can  be  found. 

The  prognosis  is  bad.  I  do  not  know  of  a  single  case  of  distinct  tuber- 
cular meningitis  that  flnally  recovered. 

Treatment. — Lumbar  puncture  should  in  all  cases  be  performed.  For 
details  regarding  technique  of  lumbar  puncture  see  chapter  on  "Epidemic 
Cerebro-Spinal  Meningitis."  Tapping  the  fourth  or  flfth  ventricle  will 
certainly  relieve  intra-cranial  pressure.  Xo  more  than  15  to  25  cubic  cen- 
timeters should  be  withdrawn  at  one  aspiration.  I  look  upon  this  as  a  very 
valuable  diagnostic  as  well  as  therapeutic  measure.  The  head  should  be 
shaved,  and  an  ice-bag  or  ice-coil  applied  continuously.  Next  in  impor- 
tance several  leeches  should  be  applied  behind  the  ears,  over  the  mastoid 
process  of  the  temporal  bone.  Cerebral  engorgement  can  also  be  relieved  by 
applying  leeches  to  the  slse  nasi ;  this  will  drain  the  blood  through  the 
frontal  sinus.     Eectal  medication  should  be  remembered. 

Large  doses  (5  to  10  grains)  of  bromide  of  sodium  and  sodium  iodide 
should  be  given  until  quiet  is  insured.  The  bowels  should  be  cleansed  by 
a  thorough  irrigation  with  glycerine  and  water.  Iodoform  collodion  (10 
per  cent.)  can  hv  a))])li('d  to  the  scalp,  tlioroughly,  once  or  twice. 

Inunctions  with  ungnentum  CrcHle  or  mercurial  ointment,  at  the  nape 
of  the  neck,  rubbed  into  the  lymphatics,  for  at  least  twenty  minutes  several 
times  a  day,  will  frequently  do  some  good. 

Pe])tonized  milk,  whey,  soups,  l)roths,  zoolak,  and  buttermilk  are  indi- 
cated.    Under  no  conditions  should  solid  food  be  administered.     If  the 


4^24  DISEASES  OF  THE  xehvuis  system. 

cliild  is  in  a  coma,  rectal  feeding  must  be  resorted  to.      (For  details  see 
chapter  on  "Rectal  Feeding.") 

Cerebko-spixal  ]\jEXiX(iiTis  (Acute  Mekixgitis,  Spotted  Fever,  or 
Maligxaxt  PuRPritic  Fever). 

Cerebro-spinal  meningitis  is  an  acute  infectious  disease  characterized 
by  a  sudden  onset  of  symptoms. 

Bacteriology  and  Etiology. — 'J'hc  ])resence  of  the  diplococcus  intra- 
cellularis  of  Wcichsclbaum  is  usually  the  causative  agent  of  this  disease.  In 
a  few  cases,  streptococci ;   in  others,  pneumococci  have  been  found. 

Weichselbaum  states  that  he  ))elieves  the  meningococcus  is  frequently 
])resent  and  lies  dormant  in  the  crypts  of  the  tonsils  and  pharynx.  For 
this  reason  he  ])elieves  that,  when  a  lowered  vitality  exists  due  to  subnornuil 
conditions,  then  the  meningococcus  gains  access  through  the  lymph  channels 
to  the  meninges  and  sets  up  an  acute  and  sudden  infection.  In  addition 
to  tlie  presence  of  the  meningococcus  in  the  tonsils,  this  pathogenic  microbe 
is  frequently  found  in  the  nose  from  whence  it  probably  gains  access  through 
the  frontal  sinuses  and  reaches  tlic  brain.  T\\e  meningococcus  can  1k'  trans- 
mitted and  an  infection  disseminated  by  direct  contact  with  infected  secre- 
tions containing  the  diplococcus  intracelhilaris.  Weichselbaum  does  not 
believe  that  tlu'  sudden  appearance  of  a  case  of  cerebro-spinal  meningitis, 
in  an  otherwise  healthy  locality,  is  extraordinary  when  the  etiological  con- 
ditions, such  as  the  possibility  of  harboring  this  diplococcus  in  the  nose  and 
throat,  are  remembered. 

Pathology. — Tn  the  early  stage  of  this  disease  we  note  hypememic 
conditions  in  the  brain  and  spinal  cord.  When  the  disease  has  progressed, 
the  arachnoid  appears  cloudy,  especially  along  tlie  course  of  the  blood- 
vessels from  which  a  purulent  exudate  oozes.  This  purulent  exudate  in- 
volves all  the  tissues  of  the  convexity  and  freijuently  extends  to  the  base  in 
the  meshes  of  the  pia  and  between  it  and  the  cortex.  The  fluid  in  the 
ventricles  is  as  a  rule  increased,  and  may  contain  small  flocculi  of  fibrin. 
Ha?morrhage  is  frequently  noted  in  this  region.  Tlie  joints  show  evidences 
of  septic  inflammation.  The  spleen  is  frequently  enlarged.  Evidences  of 
infection  and  sepsis  are  present  in  all  parts  of  the  intestinal  organs  of  the 
body.  Multiple  abscesses  may  occur,  and  not  infre(|ueiitlv  i)arenchymatous 
degenerations  involve  the  kidneys,  liver,  and  spleen. 

J'lirjjiiii'-  spoh  or  nioilliiifj.  so  fretjuenlly  seen  on  the  outside  of  the 
body,  may  sometimes  be  seen  more  distinctly  in  the  internal  organs. 

CJirnrifIr  Condilioiift. — The  greatest  number  of  cases  occur  during  the 
winter  months,  while  sporadic  cases  are  seen  in  the  s])ring,  summer,  and  fall 
months. 


PLATE  XXVI 


1.  ^leningococpiis  or  Diploeoccus  Tntraoellnlaris,  derived  from  a  Iiuiihar  punc- 
ture of  a  typical  case.      (Courtesy  of  Prof.  A.  Weicliselbaum,  of  Vienna.) 

2.  iNIeningococcus  Intracellularis,  from  a  typical  case  of  Cerebrospinal  ]\Ien- 
ingitis.     Pure  culture.      (Courtesy  of  Prof.  A.  Weichselbaum.  of  Vienna.) 

3.  Micrococcus    Catarrlialis.     Pure    culture.      (Courtesy    of    Prof.    Glion,    of 

Vienna.)      (Original.) 


CEREBROSPINAL  .MENINGITIS. 


825 


Table  No.  103. — Deaths  front  Cerebio-Hpinal  Meni)tgitis  in  Children   under 
1.3  years. — ^eic  York  City — 18f)S-lfHl7. 


Year. 

Old  New  York  City. 

Greater  Kew  York  City. 

1898 

210 

301 

1899 

232 

326 

1900 

153 

251 

1931 

1903 

1903 

ler, 

221 

15G 

221 

158 

225        I 

1904 

805 

1056 

1905 

2775 

1906 

1032 

1907 

1 

828 

Symptoms. — J)urin<;'  the  e})icleniic'  tliei'e  are  three  classes  of  cases 
encountered,  first,  a  mild  type;  second,  a  severe  type;  and  third,  an 
abortive  type. 

Mild  Type. — In  this  class  of  cases  there  is  a  slight  rise  of  temperature, 
generally  malaise,  and  perhaps  vomiting. 

Abortive  Type. — This  type  is  usually  seen  in  strong  children  who  are 
able  to  withstand  a  severe  infection.  By  reason  of  their  health  they  are 
infected  in  a  lesser  degree,  as  shown  by  their  symptoms  and  the  rapidity  of 
their  convalescence.  The  onset  is  usually  sudden,  and  T  have  seen  meningeal 
symptoms  subside  within  ten  days  with  no  sequela\  This  ha])pened  in  a 
case  of  a  child  with  undoubted  cerebrospinal  meningitis,  in  which  the 
diagnosis  was  confirmed  by  the  bacteriological  examination  of  the  spinal 
fluid,  lihinitis  with  catarrhal  discharge  from  the  nose  is  sometimes  an 
early  symptom  in  this  disease.  I'liinitis  is  fi-('(|iicntly  found  in  the  abortive 
type  of  the  disease.  Tlie  dangci'  of  liaving  the  meTiingocot-cus  in  the  nose 
consists  in  the  ease  with  whicli  this  pathogenic  bacterium  can  enter  the 
frontal  sinus  and  jlins  giv(>  rise  lo  ('iice])lialitis.  ]ii  tlie  alioi'livc  ty])e  of  this 
disease  there  fre(|uently  is  a  nasal  discharge  in  which  the  meningococcus 
intracellularis  can  be  found  long  after  the  rhinitis  has  disappeared.     The 


326  DISEASES  OF  THE  NEin'OlS  SYSTE:\r. 

ainhulatory  cases  are  tlie  ones  wliicli  disseminati.'  tliis  infection  because  they 
carry  the  pathogenic  bacteria  from  house  to  house. 

iScrerc  Type. — In  the  severe  type  there  is  a  sudden  onset  of  symptoms. 
In  okler  chiklren  a  distinct  chill  is  usually  the  first  symptom  noted.  The 
skin  feels  hot.  The  temperature  rises  anywhere  between  102-105°  F.  (38.8 
and  40.6°  C),  in  the  rectum.  The  pulse  varies,  it  may  be  slow  or  very 
rapid.  The  respiration  is  irregular  in  character,  sometimes  sighing,  and 
labored,  but  most  frequently  Cheyne-Stokes  in  character.  Later  on  there  is 
vomiting,  pain  in  the  head,  in  the  frontal  or  occipital  regions,  and  pain  at 
the  back  of  the  neck.  There  is  moaning  and  frequently  delirium.  Vaso- 
motor disturbances,  such  as  the  flushing  of  one  ear  or  one  cheek,  are 
occasionally  seen.  The  tache  cerehralc  is  usually  noted  when  stroking  the 
breast  with  the  finger  nail,  as  a  distinct  hypeni^mia  follows  and  remains  for 
several  minutes.  The  tendons  are  very  sensitive  to  the  slightest  pressure. 
The  patellar  reflexes  are  usually  absent.  When  the  thigh  is  flexed  on  the 
abdomen  and  we  try  to  extend  the  leg  there  is  considerable  latent  contraction, 
the  so  called  Kernig's  sign.  This  symptom  alone  should  not  be  depended 
uj)on.  Hyperextension  of  the  big  toe  produced  by  stroking  the  sole  of  the 
foot,  the  so  called  Babinski  reflex,  is  not  always  present.  It  is  also  fre- 
quently noted  in  ])erfectly  healthy  children.  In  a  series  of  fifty  children 
examined  by  me,  the  Babinski  reflex  was  found  in  forty. 

Either  constipation  or  diarrhoea  may  be  present.  The  bladder  acts 
well,  although  enuresis  may  exist.  In  some  cases  there  is  a  marked  retention 
of  urine.  The  joints  are  usually  swollen,  simulating  rheumatism.  There 
is  also  a  distinct  petechial  eruption  in  some  cases.  Out  of  a  series  of  twenty- 
two  cases  seen  by  me,  six  had  distinct  petechia.  In  six  others  the  skin  had  a 
distinct  eruption  resembling  scarlet  fever.  Owing  to  the  spots  present  in 
this  condition,  the  disease  was  frequently  termed  "spotted  fever."  The 
pupils  are  usually  dilated,  they  are  sometimes  irregular.  I  have  seen  cases 
during  the  epidemic  of  1905  in  which  one  pupil  showed  marked  dilatation, 
while  the  other  pupil  was  contracted  to  almost  a  pinpoint.  Strabismus  is  a 
frequent  symptom.  Occasionally  wc  note  nystagmus.  Photophobia  is  a 
frequent  symptom.  In  one  of  my  cases  the  child  cried  whenever  a  lighted 
candle  was  brought  near  the  eyes.  Opisthotonos  is  usually  present.  The 
severe  rigidity  of  the  stenocleidonuistoid  muscle  in  addition  to  the  marked 
rigidity  of  the  arms  and  legs  forms  a  very  prominent  symptom  during  the 
course  of  the  disease.  Owing  to  these  severe  contractures  we  usually  note 
constant  moaning,  most  likely  induced  by  the  pain  caused  by  the  said 
contractions. 

Diagnosis. — A  positive  diagnosis  of  this  disease  can  be  made  by  examin- 
ing the  fluid  drawn  by  luml)ar  puncture.  As  a  rule  the  spinal  fluid  is  turbid 
or  opaque.  We  do  not  find  the  S])inal  fluid  clear  and  transparent,  as  it  is 
seen  in  tuberculous  meningitis.     The  presence  of  the  characteristic  diplo- 


CEREBKO-SIMNAI.  .MENINGITIS. 


827 


coccus  intracellularis  described  by  Weichselbauiu  is  usually  noted.  In  rare 
cases  the  stre2)tococcus  and  the  pneumococcus  have  been  found,  Ijut  these 
hitter  are  the  exception.  The  bacteriological  diagnosis  according  to  Weicli- 
selbaum  depends  on  the  diplococcus  being  Gram  negative,  or  decolorized  bv 
Gram.  It  is  important  to  remember  that  the  Micrucoccus  catarrlialis  is  fre- 
(juently  found  in  the  nasal  passage,  hence  great  care  must  be  exercised  to 
differentiate  the  same,  l)oth  in  its  relation  to  Gram  staining  and  also  in  its 
morphological  characters. 

The  following  two  cases  will  serve  to  illustrate  the  method  of 
treatment : — 

Case  I. — Emilio  G.,  four  months  old,  was  admitted  to  the  Sydenham  Hospital, 
January  6,  1909.     Family  history  ntgative. 

Personal  History. — Normal   delivery.      Full   term.      Bottle-fed  since  birth. 

Present  illness  began  two  weeks  ago  with  twitchings  of  the  muscles.  One 
week  ago  mother  noticed  retraction  of  the  head.  There  had  been  no  vomiting.  The 
baby  had  moaned  almost  constantly. 

Physical  Examination. — Head  showed  bald  occiput.  The  anterior  fontanel  was 
oi)en  and  slightly  bulging.  The  pupils  were  equal  and  slightly  contracted.  There 
^^•as  marked  retraction  of  the  head,  amounting  to  opisthotonos.  The  chest  showed 
poor  expansion.  There  was  a  systolic  murmur  heard  at  the  apex  of  the  heart.  Tha 
lungs  over  left  base,  posteriorly,  showed  small  areas  of  dullness,  bronchial  voice, 
and  breathing.  The  abdomen  was  retracted.  The  liver  and  spleen  were  not 
palpable.  There  was  marked  rigidity  of  both  arms  and  legs.  The  reflexes  were 
exaggerated.  Kernig's  sign  was  not  elicited.  Lumbar  puncture  showed  turbid  fluid  in 
which  the  Diplococcus  intracellularis  was  found. 

Table  No.   iy3A. — Blood  Count. 


Before  Injection. 

After  Injection 

White  blood 
corpuscles 

Polyuuclear 
leucocytes 
Per  Cent. 

Lympho- 
cytes 
Per  Cent. 

White  blood 
corpuscles 

Polynuclear 
leucocytes 
Per  Cent. 

Lynipho- 

cvtes 
Per  Cent. 

Jan.     7 

68 
66 

17,200 

74 

26 

Jan.     8 

15,800 

34 

13,400 

64 
70 

30 

Jan.    9 

12,500 
12,300 

34 

14,200 
15.400 

30 

Jan.  11 

56 

44 

65 

35 

Jan.  13 

13,600 

6!) 

34 

14,100 

70 

30 

Jan.  15              17,800 

75 

25 

13,C00 
13,400 

68 

32 

Jan.  16 

11,500 

70 
72 

30 

73 

27 

Jan.  18 

11,500 

38 

13,400 
17,800 

73              1            27 

Jan.  20 

17,800 
17,800 

79 

21  . 

79              1            21 

Jan.  22 

74 

26 

17. £00 

78 

21 

The  <lnr;iti()n  of  the  disease  was  thirty-six  days.  Hy  means  of  ten  lumi>;ir 
punctures,  I  as|)irated  14ti  cuhic  cciiliineters  spinal  fluid,  and  in  nine  intraspinal 
injections.  I  injected  24.)  cubic  ceiif iniciers  Flexncr  seriun.  The  average  injection 
was  about  .'iO  cubic  centimeters.  The  child  made  a  complete  recovery  without  any 
sequela;. 


828 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Case  TI. — Intraventricular  Method  of  f^rruni  Injection. — Dora  R.,*  two  iiiontlis 
old  was  admitted  to  the  Babies'  Ward  of  the  Sydenham  Hospital  October  2d,  1909, 
she  was  a  well-nourished,  breast-fed  infant  having  had  no  previous  illness.  There 
was  a  sudden  onset  with  vomiting,  loss  of  appetite,  rigiditj-  of  head,  neck  and  extremi- 
ties, rolling  of  the  eyeballs,  insonuiia,  and  convulsive  movements.  The  anterior  fon- 
tanel le  was  open  V-j  inch  in  diameter,  and  slightly  bulging.  The  posterior  fontanelle 
was  almost  closed.  The  jjupils  were  equal,  and  reacted  sluggishly  to  accommodation 
and  light. 

The  thorax,  ears,  and  throat  were  excluded  as  a  possible  source  of  disease. 

On  the  fifth  day  after  admission,  and  on  two  succeeding  days,  lumbar  puncture 
was  performed  resulting  in  dry  tap.  With  the  three  successive  dry  taps,  the  symp- 
toms of  rigidity.  o)iisthotonus.  fever,  and  twitching  increased. 

On  October  20th.  T  decidi'd  to  tap  the  lateral  ventricles  by  entering  the  ante- 
rior fontanel le  at  the  right  angle.*  The  as])iration  needle,  about  8  centimeters  in 
length,  was  introduced  downward  and  toward  the  median  line,  at  an  angle  of  aboul 
20  degrees,  to  a  depth  of  about  4.5  centimeters.  The  needle  entering  the  lateral 
ventricles  near  the  median  line.  About  15  cubic  centimeters  of  turbid  purulent  fluid 
were  withdrawn,  which  was  identified  at  the  Rockefeller  Institute  as  a  meningo- 
coccus intracellularis.  Tlie  ventricles  M'ere  then  irrigated  with  normal  saline  solu- 
tion, at  body  temperature.  The  excess  fluid  was  allowed  to  drain  out  through  the 
needle,  and  25  cubic  centimeters  of  Flexner  anti-meningitis  serum  were  slowly 
injected  into  the  ventricles.  Dtiring  the  injection  of  the  serum  the  infant  changed 
in  color  from  a  waxy  pallor  to  a  uniform  red  flush  all  over  the  body.  One-half  hour 
after  the  injection  of  the  serum  the  infant  still  remained  flushed,  perspired  profusely, 
and  had  some  frothing  at  the  mouth.  Otherwise  the  general  condition  was  good. 
The  temperature  was  98  degrees  F.  respiration,  80;  and  pulse  120. 

On  October  21st.  the  ventricles  were  again  irrigated  with  40  cubic  centimeters 
of  normal  saline  solution,  and  20  cubic  centimeters  of  serum  were  injected. 

October  24th.  the  child's  general  condition  was  very  poor.  Opisthotonus  was 
marked.  The  body  rigidly  bent  in  the  form  of  a  bow.  Tlie  arms  w^ere  rigidly 
extended  and  the  palms  everted  outward. 

October  25th,  and  during  the  following  week,  daily  injections  of  30-50  cubic 
centimeters  of  serum  were  injected  either  into  the  ventricles,  or,  on  two  days,  into 
the  spinal  canal  and  lateral  ventricles.  The  total  amount  of  Flexner  serum  injected 
was  180  cubic  centimeters,  the  total  amount  retained  in  the  ventricles  and  spinal 
canal  was  about  100  cubic  centimeters. 


T.\1}LE  Xo 

.  I0?,n.— Blood  Count. 

Date 

Leucocytes 

13,400 
15,600 
17,';00 
11,400 
10,200 
11,600 
10,000 
13,S00 
10,800 

H.rm 

!!,000 

Polynuclear 

Neutrophiles 
Per  cent. 

Lymphocytes 
Per  cent. 

Ko.sinophile.s 
Per  cent. 

Oct.  .5  . 

n 

(U 
31 
88 
65 
70 
64 
71 
68 

tir, 

(10 

6'.) 
39 
69 
12 
32 
29 
31 
24 
32 
31 
37 

Oct.  13    

Oct.  22.  before  injection 

after  injection 

Oct.  26,  before  injection.   

3 

after  injection  

1 

Oct.  27 

5 
5 

Oct.  28 

Oct.  30 

Nov.  29 

Dec.  9  

3 

'  This  case  Avas  presented   at  th 
of  .Medicine,  :March  10,  1910. 
*  See  Plate  XXVII. 


Sect  inn    on    Pediatrics,    New   York    .\cadeniv 


CEREBROSPINAL  MKNINCJTTIS. 


829 


The  symptoms  are  <;ia(huilly   sul)si(liii<;.   tlic  rigidity   is  lessened,  but  on  luMiig 
handled  opisthotonus  is  very  evich'ut. 

November  29tli.  No  deciilid  change,  but  infant  inii)roving  slowly.  The  lateral 
ventricles  were  aspirated  and  oO  enbie  centimeters  of  clear  Ihnd  wliicli  did  not  con- 
tain the  meningococcus 
withdrawn. 

December  Gth.  In- 
fant was  discharged 
cured.  No  complication 
of  eyes  and  ears  existed. 

It  is  now  t\\o  months 
since  this  infant  was  dis- 
cliarged,  she  has  since  de- 
veloped a  tooth,  sleeps 
>v«dl,  nurses  wpII,  and  is 
a  happy  healthy  infant. 

Lumbar  Puncture.  1 

—  The  suljaraclmoid 
space  is  frequently  tap- 
j^ed  for  diagnostic  and 
therapeutic  purposes. 
Either  space  between 
the  third  and  fourth, 
or  the  fourth  and  fifth, 
himl)ar  vertebra^  may 
he  cliosen.  Tlie  chihl 
is  placed  on  either  side 
with  the  spinal  curve 
toward     the     onerator        ^^^^  Adapted  Un-  Lumbar  Puncture.     The  needle  should 

be  inserted   in  the   lumbar   space   shown   by  the   cross. 


Fig.  269. — Anatoniicrd  Illustration  Showing  the  Place 


in  this  way  spreading 


(Ori-nual  ) 


the  vertebne  so  that 
the  greater  angle  formed  l)y  the  vertebra^  is  toward  the  o]ierator.  An 
imaginary  line  drawn  through  the  crest  of  the  ilium  to  tlie  spine  is  an  easy 
means  of  locating  the  place  to  ]nincture. 

Kind  of  Xccdlr  nrijiiiri'd. — In   making  a   hinibar  ]nincture  we  slu^dd 
use  such  a  needle  as  would  be  r('(piireil  in  nuiking  a  puncture  for  euipyeuia. 


Fig.  2/0. — Lumbar    Puncture   Needle. 


The  needle  shotdd  be  })uslicd  a  little  u])wai-(l  and  forward  until  it  enters  the 
spinal  canal,  then  the  stylet  shoidd  be  withdrawn.  If  the  fluid  does  not 
escape  through  the  needle,  then  witlidi-aw  it  slightly  and  reintroduce  the 
stylet  to  dislodge  any  olistiniciio))  in  ibe  caliber  of  the  needle.     Make  the 


1  First  described  bv  (Quincke. 


830 


DisKASKS  OF  TiiK  NKmors  svs■l■l•:^r. 


puncture  as  siiii})k'  as  possihle  rallu'r  than  laei-rate  the  tissue  around  the 
vertebral  column  and  cause  bleeding  by  lateral  movements  of  the  needle. 

Anioiinl  of  Fluid  fo  he  Witlidnncii. — For  diagnostic  purposes  15  to  20 
cubic  centimeters  sbould  l)e  withdrawn,  it'  the  fluid  is  watery  and  clear.  If 
the  spinal  fluid  is  turl)id  then  the  more  we  can  withdraw,  the  better.  I  have 
withdrawn  as  much  as  50  to  GO  cubic  centimeters.  If  the  diplococcus  intra- 
cellularis  is  found  in  the  spinal  fluid,  it  is  especially  important  to  with- 
draw as  much  of  tlie  fluid  as  possible. 

The  site  of  puiu-ture  shouhl  l)e  closed  with  a  strip  of  adhesive  plaster. 


271. — Luiubar   ruin  t\nv  Aladr  li.'lwicii   Fimrtli  and  Fifth  Lumbar 
Vtntt'bnr.      (Oiijiiual. ) 


Jjxal  AiKi'sllirsia.—yAhy]  cliloride  in  tlie  form  of  a  spray  is  nseful  in 
very  sensitive  children.  It  is  not  necessary  to  have  general  ana?sthesia 
during  tliis  procedure.  General  rules  of  asepsis  must  be  strictly  applied  to 
the  chihl's  skin,  the  operator's  hands,  and  to  the  needle  used. 

Dry  Tap  in  Luinhar  Puncture. — We  nuiy  have  a  dry  tap: — 

1.  If  the  caliber  of  the  needle  is  small,  and  the  spinal  fluid  very  thick. 

2.  If  adhesions  are  present  at  the  base  of  the  l)rain,  preventing  the 
passage  of  fluid  from  tlie  ventricles  to  the  suljarachnoid  space. 

3.  If  a  successful  puncture  has  been  nuide,  a  dry  tap  nuiy  follow,  due 
to  inflammatory  adhesions  caused  Ijy  the  previous  introduction  of  the  needle. 

4.  The  closing  of  the  i'oramen  of  ^lagendie  is  the  most  frequent  result 
of  the  inflammatory  process,  resulting  in  dry  ta]i. 

5.  A  fibrin  clot,  or  the  presence  of  the  cord  in  front  of  the  needle  may 
prevent  the  outflow^  of  the  cerebro-spinal  fluid. 

To  be  sure  that  we  are  in  the  spinal  canal,  if  a  dry  tap  exists,  leave 
the  needle  in  situ  and  introduce  a  second  needle  two  spaces  lower.  Sterile 
water  if  injected  through  the  upi^er  needle  will  flow  out  of  tlie  lower  needle, 
proving  that  we  are  in  the  spinal  canal. 


fEREBRO-SIMXAI.   M  KXlXriTTTP.  §31 

The  spinal  cord  in  infants  terniinatts  abor.t  the  level  of  the  lumbar 
vertebi'ffi.  The  introduction  of  the  needle  is  simplest  between  the  third  and 
fourth,  or  the  fourth  and  fifth,  luml^ar  vertebra?.  In  these  interspaces  there 
is  no  cord,  hence  no  injury  can  foHow.  An  imaginary  line  drawn  throuj^h 
the  crest  of  tlie  ilium  corres])onds  to  tlie  fourth  intercostal  space. 

Prognosis  and  Sequelae. — Heretofore  the  prognosis  was  always  l)ad  ; 
since  the  introduction  of  the  Flexner  serum  a  decided  improvement  has  been 
noted.  Where  formerly  TO  to  80  cases  died  and  only  20  to  30  cases 
recovered,  we  now  have  the  reverse,  70  to  80  recoveries  and  only  20  to  30 
deaths.  The  prognosis  is  better  if  the  serum  treatment  is  given  early  in 
the  disease. 

The  duration  of  this  disease  nuiy  l)e  sliort  or  very  long.  Young  infants 
have  Ijeen  attended  by  me  more  than  two  months  until  recovery  took  place. 
Some  cases  after  serum  treatment  recover  entirely,  others  have  atrophy  of  tlie 
ojitic  nerve  resulting  in  blindness.  Deafness  is  a  frequent  and  permanent 
injury  in  some  cases. 

Treatment. — Fever  Treatment. — Antipyretic  measures  such  as  cold 
packs,  ice  bag  on  the  head,  and  tub  baths  are  indicated.  The  coal-tar 
products,  owing  to  their  depressing  effect  upon  the  lieart,  shouhl  be  avoided. 
Cupping  of  the  neck  and  spine  sometimes  relieves  internal  congestion. 
Lumbar  puncture  should  be  performed. 

Eliminative  Treatment. — This  consists  in  cleansing  the  gastro-intes- 
tinal  tract  with  the  aid  of  citrate  of  magnesia  or  calomel.  ^Yhen  high  fever 
exists,  flushing  the  rectum  and  colon  with  a  cold  soap-suda  enema  will  be 
fottnd  useful. 

Medicinal  Treatment. — To  relieve  the  vomiting  cracked  ice  should  be 
given,  in  addition  to  1-grain  doses  of  menthol.  To  relieve  muscular  spasm, 
twitching,  and  delirium,  hyoscine  hydrol)roniate,  in  doses  of  Vgoo  to  '^/^na 
grain,  should  be  given  and  repeated  every  few  hours.  ]\Iorphine  hypo- 
dermically,  in  doses  of  V^q  grain,  gradually  increased,  is  also  valuable. 
Leeches  applied  at  the  nape  of  the  neck  or  over  the  mastoid  portion  of  the 
temporal  bone  or  at  the  alae  nasi,  will  sometimes  relieve.  Sodium  bromide, 
in  0  to  30-grain  doses,  may  be  given  until  the  systemic  effect  is  noted. 
Codeine,  Vio  grain  gradually  increased  until  i/^  grain  is  given,  will  fre- 
quently soothe  the  nervous  system.  The  soothing  effect  of  a  warm  bath  is 
generally  recognized.  The  batli  should  be  given  at  a  temperature  of  100° 
to  105°  F.  in  a  bath  tub  of  water  to  which  14  to  1,^  pound  of  sulphur  has 
l)een  added.  A  warm  sulphur  bath  may  l)c  given  twice  a  day.  The  dura- 
tion of  each  bath  should  be  at  least  ten  to  thirty  minutes. 

Meningitis  Serum.'^ — The  specific  value  of  tbe  anti-meningitis  serum 
lias  been  demonstrated  many  times.     In  some  cases  re])orted  tlicre  has  been 

I  I  am  iii(l("l)tc<l  to  Di'.  Simon  Floxncr  of  tlic  Rockefeller  Iiistilutc  for  tlic  ;iiiti- 
meningitis  senini  used  in  these  cases. 


(i^p^o  DisKASKs  OK  riiK  NKinois  svstk:\[. 

a  siuhk'n  crisis  ami  an  ainolioratiou  ol  all  the  symptonis.  My  experience 
has  l)een  especially  good  in  young  inl'ants  under  one  year.  While  formerly 
all  inl'ants  of  tender  age  died,  we  now  have  a  numher  of  cases  reported, 
including  my  own,  in  which  absolute  recovery  has  taken  place. 

Intraspinal  Injcdluiis. — By  lumbar  puncture  we  aspirate  as  much  of 
the  spinal  fluid  as  ])ossil)le,  in  some  cases  15  to  30  cubic  centimeters  was 
f)l)tained.  Through  the  same  needle  left  in  situ  I  inject  from  30  to  GO  cubic 
centimeters  of  Flexner's  serum.  The  serum  should  be  warmed  before 
injecting,  and  should  l)e  injected  slowly.  It  is  l)etter  to  elevate  the  hips  and 
lower  the  head  when  injecting  the  serum.  Daily  injections  of  30  to  60  cubic 
ccntiiiu'ters  are  required  if  no  improvement  is  noted. 

Intracranial  Injcclions^ — The  scalp  should  be  shaved  and  prepared 
with  the  usual  aseptic  precautions.  The  aspirating  needle  must  be  rendered 
sterile  by  boiling,  it  is  then  pushed  through  the  anterior  fontanelle  down- 
ward and  inward  into  the  ventricles  of  the  brain,  at  least  one  inch  or  more. 
'J'he  needle  is  inserted  about  one-fourth  inch  to  one  side  of  the  longitudinal 
sinus. 

At  the  Babies'  Wards  of  the  Sydenham  Hospital  we  have  aspirated 
many  times,  50  cubic  centimeters  of  purulent  liquid  containing  the  diplo- 
coccus  intracellularis  in  almost  a  pure  culture.  By  using  this  same  needle 
or  one  having  a  larger  caliber,  we  irrigated,  using  a  pint  of  normal  saline 
solution.  After  draining  off  as  much  as  possible;  50  cubic  centimeters  of 
Flexner's  .«erum  were  injected.  This  plan  of  treatment  was  successfully 
used  in  two  of  my  cases.  In  both  cases  the  lumbar  puncture  yielded  a 
dry  tap,. 

The  purulent  discharge  gradually  lessened  and  the  meningococci  grad- 
ually disappeared,  after  continued  serum  injections  extending  over  a  period 
of  four  weeks.  It  was  possible  to  aspirate  and  draw  off  between  50  and  Co 
cubic  centimeters  of  a  clear  transparent  hydrocephalic  fluid  containing  no 
germs. 

A  decided  I'eaction  followed  each  and  every  injection  of  serum.  During 
the  injection  of  serum,  tho  child  changed  in  color  from  a  waxy  pallor  to  a 
uniform  red  flush  all  over  the  body.  One-half  hour  after  the  injection  of 
the  serum,  the  child  still  lemained  flushed  and  perspired  profusely,  and  had 
some  frothy  mucus  at  the  mouth. 

The  pulse  rate  was  increased,  the  volume  improved,  and  the  tension 
much  higher.  The  leucocytes  were  invariably  increased.  The  polynuclear 
leucocytes  were  also  increased  after  each  injection.  As  a  rule  the  mono- 
nuclear leucocytes  and  the  l\TTiphocytes  were  reduced  within  six  hours  after 
the  serum  injection. 


1  I  am  in(];'l)ted  to  my  house  staff.  Dr.  Bobrow,  Dr.  C'luimaii.  Dr.  Littenberg 
and  Dr.  Frciinfl  for  careful  notes  and  records  of  a  series  of  cerebro-spinal  meningitis 
cases  treated  at  tlie  hospital.     See  clinical  case,  page  828. 


PLATE  XXYII 


Translucent  Head  of  Child.  The  needle  entering  the  outer  angle  of  the 
anterior  foutanelle,  and  penetrating  the  lateral  ventricle,  which  is  seen  in  shaded 
outline.  The  falx  is  dimly  seen.  The  riglit  line  runuing  from  before  back- 
wards is  the  septum  lucidum  dividing  the  two  ventricles.     (Original.) 


CHRO:SIC  PACHYMENINGITIS.  ,S33 

Feeding. — Unless  the  strength  is  supported  by  food  our  patient  will 
die  of  exhaustion.  Feeding  by  mouth  with  peptonized  milk,  broth,  gruel, 
and  eggs  is  indicated.  If,  however,  there  is  vomiting  and  the  stomach  does 
not  retain  food,  then  rectal  feeding  should  be  resorted  to  at  intervals  of 
three  or  four  hours.  This  method  of  feeding  has  already  been  described 
in  the  chapter  on  "Infant  Feeding." 

After  Treatment. — If  tlie  case  j^rogresses  favorably,  careful  attention 
must  be  given  to  restorative  treatment.  Codliver-oil,  Fowler's  solution, 
iodide  of  sodium,  and  the  hypophosphites  must  not  be  forgotten.  Electricity 
must  not  be  forgotten  comljined  with  massage  and  sea-salt  bathing.  They 
are  indicated  during  convalescence.  Milk,  cream,  butter,  eggs  and  cereals 
f hould  form  the  bulk  of  restorative  nutrition.  A  decided  change  of  air  from 
the  city  to  the  ?ea-shore  or  to  the  mountains  will  prove  beneficial. 

Acute  Pachymexingitis   (Inflammation  of  the  Dura  Mater). 

This  condition  frequently  follows  middle-ear  disease,  although  it  may 
be  the  result  of  injury  to  the  cranium.  It  is  frequently  associated  with 
inflammation  of  the  pia  mater  (leptomeningitis).  It  is  very  difficult  to 
diagnose.  It  usually  follows  ear  disease  and  the  symptoms  of  meningitis  are 
associated.     The  treatment  is  surgical. 

Chronic  Pachymeningitis. 

Chronic  pachymeningitis  can  be  divided  into  two  forms — hnsmorrhagic 
and  non-lianiorrhagic.  There  may  be  punctate  ha-morrhages  or  there  may 
be  very  large  hamiorrhagic  areas.  Some  authors  state  that  this  condition 
is  very  rare.  It  affects  the  inner  layer  of  the  dura  mater.  It  is  frequently 
called  pseudo-membranous  and  luemorrhagic,  or  hematoma  of  the  dura 
mater. 

In  cases  where  life  is  prolonged  for  years,  there  may  be  partial  or  even 
complete  absorption  of  the  clot,  followed  by  the  formation  of  cysts,  con- 
siderable inflammatory  thickening  of  the  pia  with  deposits  of  blood  pigment, 
and  finally  atrophy  and  sclerosis  of  the  cortex.  The  source  of  the  hipmor- 
ihage  may  be  the  rupture  of  a  single  large  vessel,  but  more  frequently  the 
Ijlood  comes  from  many  small  vessels. 

Symptoms  and  Diagnosis. — It  is  very  difficult  to  give  positive  symptoms 
by  wliich  tliis  condition  can  be  recognized  during  life.  Coma,  convulsions, 
stupor,  and  vomiting  are  the  main  symptoms.  Unilateral  ha?morrhage  causes 
rigidity  affecting  one  arm  and  leg,  but  if  the  hemorrhage  is  diffused  all 
the  extremities  are  affected.  The  pupils  may  be  dilated  or  contracted; 
sometimes  one  pupil  is  dilated  and  the  other  is  contracted.  The  respira- 
tion and  pulse  are  slow  and  irregular.  There  is  usually  fever,  the  tem- 
perature being  as  high  as  105°  or  as  low  as  100°  F. 

53 


834  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Opisthotonos  may  be  absent.  The  patellar  reflex  is  usually  exag- 
gerated.    Convulsious  appear  and  death  ends  the  scene. 

The  differential  diagnosis,  according  to  Holt,  is  as  follows:  "Without 
large  haemorrhages,  pachymeningitis  interna  cannot  be  diagnosticated ;  and 
it  is  impossible  to  differentiate  the  haemorrhagic  cases  from  other  varieties 
of  meningeal  haemorrhage.  It  is  important  to  make  a  diagnosis  between 
pachymeningitis  with  hemorrhage,  and  acute  simple  meningitis.  In  the 
former  we  liave  a  sudden  onset;  stupor  occurring  early,  usually  on  the 
first  day,  gradually  diminishing  in  cases  of  recovery,  or  deepening  into 
coma  in  fatal  cases;  localized  or  general  paralysis,  also  occurring  early; 
there  is  no  fever  in  the  beginning,  and  only  moderate  fever  at  the  close. 
In  acute  meningitis  we  usually  have  a  higher  temperature,  especially  early 
in  the  disease;  coma  develops  later,  and  rigidity  of  the  extremities  is  less 
pronounced.  In  certain  cases,  however,  where  the  hiemorrhage  occurs  in 
the  course  of  some  other  disease,  a  differential  diagnosis  may  be  impossible." 

The  prognosis  is  usually  fatal.  If  small  haemorrhages  take  place,  the 
paralysis  may  remain  for  years. 

Treatment.  —  Tlie  scalp  should  be  shaved  and  an  ice-bag  applied. 
Leeches  should  be  applied  to  the  mastoid  to  relieve  cerebral  congestion. 
Large  doses  of  bromide  and  ergot  will  sometimes  do  good.  The  emunc- 
tories  must  be  carefully  watched  and  aided  if  necessary. 

Cerebral  Paralysis  (Spastic  Diplegia.      Paraplegia. 
H^emiplegia). 

There  are  two  forms  of  palsy  usually  seen.  When  the  face,  arm,  or 
leg  is  palsied  it  is  called  monoplegia.  When  the  two  lower  extremities  are 
affected,  paraplegia.  Wlien  one  side  is  affected,  haemiplegia.  When  both 
sides  are  affected,  diplegia. 

They  occui;  in  one  of  three  periods :  first,  during  intra-uterine  life 
(prenatal)  ;  second,  traumatism  during  labor;  third,  palsies  after  birth 
of  the  child. 

Etiology. — Injury  to  the  mother  frequently  injures  the  cerebrum  of 
tlie  foetus.  Toxic  conditions,  especially  those  associated  with  the  infec- 
tious disease  resulting  in  nuiscular  degeneration,  frequently  cause  palsy. 
Compression  of  the  infantile  brain  and  its  circulation  during  a  slow  labor 
may  produce  thrombosis  or  meningeal  hajmorrhage.  This  condition  is  most 
liable  to  occur  in  a  primipara.  Whooping-cough  has  caused  cerebral  ]ia3m- 
orrhage  and  injury  and  compression  to  the  cortex  ending  in  paralysis. 

Syphilis  may  be  a  frequent  cause  of  this  condition.  Epilepsy  is  found- 
in  over  two-thirds  of  all  cases  as  a  sequela. 

Pathology. — Very  interesting  data  are  contributed  by  Peterson  and 
Sachs,  t(j  wliom  I  am  indel)ted  for  the  following  classification : — 


CEREBRAL  PARALYSIS. 
Table  No.  104. 


835 


Groups. 


I.       Paralyses  of  intia-uteriue  onset. 


II.     Paralyses      occurring    during 
labor. 


III.    Paralyses  acquired  after  l)irtli. 


Pathological  Changes. 


Lakge  Cerebral  Defects  (true  porencephaly). 

HiEMOERHAGES  OF  Intra-uteeine    Origin    (soft- 
ening?). 

Agenesis  Coeticalis. 

Meningeal    Hemorrhage   (very  f^eldom  intra- 
cerebral). 
Resulting      conditions :       meningo-encephalitis 
chronica  ;  sclerosis  ;  cysls  ;   atrophies  (poren- 
cephalies). 

Meningeal  Hemorrhage  (very  seldom  intra- 
cerebral) ;  Embolisji  ;  Thrombosis  (in 
marantic  conditions  and  occasionally  frt  ni 
syphilitic  endarteritis). 
Results  of  these  vascular  lesions  ;  cysts  ;  soften- 
ing ;  atrophy  ;  s^clerosis  (diffuse  and  lobar). 

Chronic  Meningitis. 

Hydrocephalus  (seldom  the  sole  cause). 

Primary  Encephalitis  (Striimpell)  (?). 


"A  summary  of  the  pathological  lesions  resulting  from  acute  ap- 
oijlexies  consists  of  atrophies,  sclerosis,  and  other  changes  due  to  ha^mor- 
rliage;  also,  embolism  and  thrombosis.*' 

"Fatty  degeneration  of  the  blood-vessels  is  the  probable  explanation 
of  the  escape  of  blood  in  a  large  number  of  cases."  Heart  lesions,  pneu- 
monia, and  other  infectious  diseases  predispose  to  embolism. 

The  secondary  changes  result  in  sclerosis  or  areas  of  softening.  "The 
sclerosis  is  largely  responsible  for  the  imbecility  and  epilepsy;  transverse 
fibers  connecting  intimately  all  parts  of  the  hemispheres." 

Spencer  studied  130  cases  of  still-bom  children.  He  found  53  cases 
due  to  ha-morrhago  from  the  pia  and  arachnoid.  In  29  cases  there  was 
bilateral  h^Binorrhage,  10  in  the  left  side  only;  10  in  the  right  side;  7 
in  the  lateral  ventricles;  6  at  the  base  of  the  brain;  1  case  of  intra-cere- 
I)ral  haemorrhage;  4  cases  of  thrombosis  of  the  longitudinal  sinus. 

The  following  case  occurred  in  the  practice  of  Dr.  A.  C.  Cotton,  of 
Chicago : — 

Edith  N.,  age  10  years,  ohlcst  in  family  of  four  chihlren.  Others  normal. 
Mother  not  in  good  health  during  gestation.  Labor  lasted  twelve  hours.  No 
forceps.  Child  was  always  irritable,  but  had  no  convulsions  until  four  months  of 
age,  Avhon  first  tooth  appeared.  There  were  frequent  recurrences  of  spasms,  two  to 
four  daily.  Has  never  walked,  stood  alone,  nor  been  able  to  support  her  liead.  Tlin 
circumference  of  the  head  was  nineteen  iiiehes. 


836 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


I'rcucnt  Condition. — The  skin  is  cool,  with  a  tendency  to  cyanosis.  The  body 
is  emaciated;   there  is  a  Uaiing  of  the  ribs,  and  the  spleen  shows  a  distinct  scoliosis. 

The  mouth  is  open  so  that  tlie  saliva  constantly  dribbles.  The  jaws  are  de- 
formed and  the  face  presents  a  starched  appearance.  There  are  contractures  and 
spasticity  in  both  upper  and  lower  extremities.  The  reflexes  are  exaggerated.  In- 
telligence nil. 

Symptoms  and  Diagnosis. — The  following  symptoms  are  common  to  all 
forms  of  palsy :  Jxigidity  of  the  muscles,  contraction  of  tendons,  and  exagger- 


Fig.  272. — Infantile  Cerebral  Paralysis.     (Kindness  of  Dr.  A.  C.  Cotton.) 


ation  of  all  the  deep  reflexes.  ComT.ilsions  and  coma  commonly  precede  the 
diseased  state.  Most  cases  of  diplegia  and  paraplegia  are  congenital,  while 
most  cases  of  ha'miplegia  are  ac(iuired  after  hirth. 

Palsies  usually  follow  a  diflicult  l;il)or.  Strahismus  and  facial  paralysis 
are  frcHpiently  noticed.  Aphasia  may  he  present  in  children  that  had 
previously  learned  to  talk.  The  reflexes  on  the  afl'ected  side,  knee  and 
elhow,  are  usually  exaggerated  (Peterson,  Taylor,  and  Wells). 

When  athetosis  is  found,  it  is  usually  associated  with  imhecility  and 
idiocy. 

In  associated  movements  the  exact  imitation  of  tlie  2)arahjzed  hand 


CEREBRAL    PARALYSIS.  837 

and  fingers  of  voluntary  movements  made  by  the  normal  hand  and  fingers 
takes  'place.  Choreiform  movements,  called  by  Weir  Mitchell  post-paralytic 
chorea,  are  frequently  mistaken  for  chorea.  Peterson^  describes  two  con- 
genital hsemiplegias — a  hitherto  unnoted  morbid  movement  to  which  he  has 
given  the  name  post-hcemiplegic  poly  myoclonus.  The  movements  are  neither 
choreiform  nor  athctoid,  but  are  constant  clonic  contractions  of  most  of  the 
muscles  in  the  limbs  affected,  not  occurring  synchronously,  and  the  rhythm 
being  about  that  of  paralysis  agitans  (five  per  second).  All  of  these  move- 
n\ents  indicate  interference  with  motor  conduction  due  to  lesions  in  some 
part  of  the  voluntary  and  inhibitory  tracts. 

The  following  schedule  of  symptoms  by  Jacobi  is  useful  in  showing  the 
diagnostic  features  of  the  different  palsies : — 

Upper  Extremity. — Deltoid:  Absence  of  deformity,  which  is  averted 
by  weight  of  arm.  Inability  to  raise  arm.  Sometimes  subluxation.  Fre- 
quent association  with  paralysis  of  biceps,  brachialis  anticus,  and  supinator 
longus. 

Lower  Extremity. — Ilio-psoas:  Eare  except  with  total  paralysis.  As- 
sociated with  paralysis  sartorius.  Loss  of  flexion  of  thigh.  Limh  extended 
(if  glutei  intact). 

Gtutei. — Thigh  adducted.  Outward  rotation  lost.  Lordosis  on  stand- 
ing.    Frequent  association  with  paralysis  of  extensors  of  back. 

Quadriceps  E.vtensor. — Flexion  and  adduction  of  leg  (if  hamstrings 
intact).  Loss  of  extension  of  leg.  Frequent  association  with  paralysis  of 
til)ialis  anticus. 

Tibialis  Anticus. — Often  concealed  if  extensor  communis  intact.  If 
both  paralyzed,  then  fall  of  point  of  foot  in  ecpiinus.  Dragging  point  of 
foot  on  ground  in  walking.  F)ig  toe  in  dorsal  flexion  (if  extensor  poUicis 
intact).  The  tendons  prominent.  Hollow  sole  of  foot  (if  peroneus  longus 
intact). 

Extensor  Communis. — Nearly  always  associated  witli  that  of  tibialis 
anticus.     Toes  in  forced  flexion. 

Peroneus  Longus. — Sole  of  foot  flattened.  Point  turned  inward.  In- 
ternal border  elevated. 

Sural  Muscles. — Heel  depressed.  Foot  in  dorsal  flexion  (calcaneus). 
Sole  hollowed  if  peroneus  longus  intact;  flattened  if  paralyzed-.  Point 
turned  outward    (calcaneo-valgus). 

Extensors  of  Bad-. — Lordosis  on  standing.  Projection  backward  of 
shoulders.  Plumb-line  falls  behind  sacrum  (unilateral).  Trunk  curved  to 
side.    Trunk  cannot  ])e  moved  toward  paralyzed  side. 

Abdominal  Muscles.  —  Lordosis  without  projecting  backward  of 
shoulders. 


^  Starr.  AnicMicaii  Toxt-hook  Diseases  of  Children,  p.  652. 


S38  DISEASES    or    THE    NEllVOL'S    SYSTEM. 

EigidiUj  and  contractures  are  striking  syinptoins  in  almost  all  these 
palsies,  and  for  this  reason  they  often  fall  into  tlie  hands  of  the  ortho- 
paedic surgeons,  who  arc  besought  to  remedy  the  rigidly-flexed  elbows, 
wrists,  knees,  and  the  various  deformities  that  interfere  with  locomotion. 
Adductor  spasm  in  the  thighs,  causing  cross-legged  progression,  is  nearly 
constant  in  di])k\gia  and  i)arapU'gia.  Talipes  equino-varus  is  the  most  fre- 
(juent  jjcdal  deformity  in  htvmij)legia.  IJarcly  talipes  equinus  and  talipes 
t'(iuiiu)-vidgus  are  to  be  found  in  h;vmiplegia.  While  rigidity  with  con- 
tracture is  the  rule  in  all  of  these  forms  of  infantile  cerclu'al  palsy,  occa- 
sionally, but  very  seldom,  cases  will  be  met  with  in  which  the  muscles  are 
all  completely  flaccid.  '^Phe  chief  trophic  disturbance  encountered  in  these 
cases  is  retardation  in  growth  of  the  paralyzed  member.  The  paralyzed 
limbs  do  grow,  but  at  a  much  slower  rate  than  the  sound  extremities. 
Hence  the  disproportion  is  often  very  striking.  The  earlier  the  onset 
of  tlie  palsy,  the  greater  is  this  disproportion.  Another  peculiarity  noted 
is  that  the  growth  of  the  whole  organism  is  to  a  certain  extent  inter- 
fered with,  the  injury  to  the  brain  seeming  to  stunt  development  and 
to  prevent  the  patient  attaining  his  normal  stature.  The  patients  are  more 
or  less  undersized  and  dwarfed.  Peterson  describes  a  case  in  which  the 
mother  brought  to  him  her  two  boys,  twins,  6  years  of  age,  for  the  exami- 
nation of  the  one  affected.  One  was  a  tall,  well-built  lad;  the  hasmiplegic 
boy  was  small-bodied  and  fully  seven  inches  shorter  than  his  healthy 
brother.  In  all  of  these  cases  the  muscles  of  the  paralyzed  and  undevel- 
oped extremities  react  normally  to  the  faradic  current.  There  is  no  re- 
action of  degeneration.  In  many  cases  the  affected  limbs  may  be  blue  and 
cold,  as  in  paralysis  of  the  spinal  type.  A  very  rare  phenomenon  in  these 
cases  is  a  hypertrophy  of  the  muscles,  usually  combined  with  athetosis. 

Asymmetry  of  face  and  skull  have  been  observed.  Peterson  and  E.  D. 
Fisher  have  called  attention  to  the  flattening  of  the  skull  on  the  side  op- 
posite tlie  ])aralysis  in  infantile  spastic  haemiplegia. 

Differential  Diagnosis. — From  infantile  spinal  paralysis  we  can  dif- 
ferentiate, by  the  presence  of  the  exaggerated  reflexes,  the  rigidity  and 
normal  reaction  of  the  muscles.  In  cerebral  palsy  there  is  no  actual  atrophy 
in  the  limbs.  When  the  central  neuron  is  involved,  the  inhibitory  influence 
over  reflex  manifestation  is  lost;  consequently  there  is  an  increased  reflex. 
When  the  peripheral  neuron  is  involved,  the  circuit  being  broken,  the  reflex 
is  lost.     Tliere  are  no  marked  trophic  changes. 

Prognosis  and  Course. — In  diplegia  and  paraplegia  due  to  intra-uterine 
or  l)irth^  lesions  they  rarely  reach  the  third  year.  As  a  rule  they  die  of 
marasmus  in  infancy.  In  hivmiplegia  the  prognosis  is  better.  In  most 
cases  the  paralysis  may  improve  and  the  brain  may  not  be  seriously  im- 


*  See  article  on  "Erb's  Paralysis  or  Birth  Palsy  in  the  New-born  Baby." 


PLEUKOPLEGIA.  339 

paired.  If  epilepsy  appears  in  later  life,  we  may  suspect  a  previous  infau- 
tile  paralysis. 

The  palsy  affecting  the  face  and  the  leg  can  usually  be  improved. 
Speech  will  also  gradually  return  if  improvement  is  noted.  The  late  ap- 
pearance of  epilepsy  must  not  be  forgotten.  Sometimes  the  paralysis  is 
present  a  year  or  more  before  the  onset  of  the  epilepsy  (Peterson). 

Treatment. — If  convulsions  are  present,  the  inhalation  of  chloroform 
or  laughing  gas  is  indicated.  Anti-spasmodics,  such  as  bromide  of  potas- 
sium or  bromide  of  sodium,  with  or  without  chloral  hydrate,  can  be  given. 
General  attention  to  the  stomach  and  bowels — and  dietetic  management 
is  certainly  indicated.  Iodide  of  sodium  is  also  indicated.  Counter-irritants 
cause  excitement-  and  sometimes  do  harm.  J.  Madison  Taylor  advises 
against  the  use  of  counter-irritants.  Electricity  combined  with  massage 
is  useful.  The  f aradic  interrupted  current  will  do  good  by  stimulating  the 
muscles.  The  current  should  be  used  daily;  besides  careful  massage 
(muscle  kneading),  passive  movements  are  of  great  importance.  This  form 
of  exercise  should  be  resorted  to  and  more  good  can  le  done  by  this  form  of 
treatment  than  by  all  medication.  We  must  not  expect  the  bodily 
functions  to  return  to  normal  until  we  have  strengthened  the  body  with 
restorative  treatment,  combined  with  fresh  air,  and  by  all  means  light 
•nutritious  food. 

Some  cases  will  not  yield  to  medicinal  treatment,  and  here  surgical 
procedure  has  been  advised.  Neither  trephining  nor  craniectomy  have  been 
successful.  Allen  Starr  reports  in  a  recent  paper  that  in  fifty  cases  oper- 
ated, in  these  and  allied  conditions,  the  results  were  not  encouraging. 

A  rhild  3  years  old  was  brought  to  my  clinic  at  the  New  York  Post-gi-aduate 
Medical  School  and  Hospital  in  1894.  It  was  suffering  with  backward  development 
and  had  distinct  evidences  of  cerebral  palsy.  There  was  a  diplegic  paralysis.  The 
head  was  microcephalic.  As  nothing  could  be  done  by  general  routine  treatment,  it 
was  decided  to  try  surgical  treatment.  A  craniectomy  was  performed  by  Dr. 
Seneca  D.  Powell.    The  child  died. 

Two  other  cases  known  to  me  have  been  operated,  and  the  surgical 
treatment  in  each  has  been  disappointing. 

Pleuroplecjia  (Mobius'sche  Kernsciiwund). 

This  is  a  congenital  condition  caused  by  a  combination  of  abducens, 
facial,  and  hypoglossal  paralysis. 

This  condition  is  caused  by  nuclear  defects,  and  the  partial  palsies 
are  evidently  due  to  lack  of  intra-uterine  development.  The  following 
case  illustrates  this  condition : — 

C.  M.  G.,  born  May  4,  1898,  was  referred  to  me  for  diagnosis  by  Dr.  Henry  A. 
Bernstein. 

Family  History. — U  is  the  first  child.     The  motlier  has  had  two  miscarriages 


840 


DISEASES    OF    THE    NERVOUS    SYSTEM, 


since   the  birth  of  this  child.     Tho  parents  are  not  related  by  birth.     Syphilis  can 
be  positively  excluded. 

'Vhild'.f  llifitory. — She  was  breast-fed  for  tliree  months;  later  received  bottle 
feeding.  When  live  months  old  it  was  noticed  that  the  infant  could  not  support  its 
head.  Dentition  began  at  seven  and  one-half  months.  Did  not  walk  until  the  tliird 
year.  Had  measles  and  also  diarrluca  about  this  time  and  ceased  walking,  but  began 
to  walk  again  during  the  fifth  year.  Talking  began  when  5  years  old.  Could  not 
connect  words  until  G  years  old.  Is  inclined  to  constipation.  Adenoids  were  re- 
moved when  3  years  old. 

St.  pr. — Now  7  years  old.  The  heart  sounds  are  clear  and  normal,  although 
heart  action  is  slow  (bradycardia).  The  head  moves  nonnally.  There  is  a  funnel- 
shaped  dejjression  of  the  thorax,  also  a  spinal  curvature,  pendulous  belly,  carious 
teeth,  besides  other  symptoms  of  rickets.  The  nanolaUinl  folds  are  totally  absent. 
There  is  an  absence  of  expression — no  difference  in  laughing  or  crying.  The  saliva 
flows  out  of  the  mouth.  The  eyes  do  not  close  during  sleep  (lagophthalmus) .  The 
iris  disappears  imder  the  lids  in  attempting  to  close  them.  There  is  an  absence  of 
the  secretion  of  tears.  No  fibrillary  contractions  of  the  tongue  are  visible.  The 
uvula  is  in  the  median  line  just  as  in  the  normal  child. 

Treatment. — Kestorative  treatment  consisting  of  proteid  food  and  general 
hygienic  treatment  to  improve  the  rachitis  was  ordered. 

Codliver-oil  aud  phosphorus  may  be  tried,  as  also  large  doses  of  iodide 

of  sodium.     Faradic  electricity  is  indicated. 

Pseudohypertrophic  Paralysis  (Muscular  Pseudohypertrophy). 
We  are  indebted  to  Duchenne  for  an  accurate  clinical  description  of 
this  condition. 

Etiology. — This  disease  is  usually  found  in  children  between  the  sec- 
ond and  eighth  years.  It  is  more  frequently 
observed  in  males  than  in  females.  There  is 
no  distinct  cause  of  this  disease. 

Pathology. — The  pathological  lesions 
noted  are  a  fatty  infiltration  of  the  muscles, 
changes  in  the  breadth  and  contour  of  the 
nuiscular  fibers,  and  an  increase  in  the  inter- 
muscular connective  tissue. 

Symptoms. — Motor-weakness  is  usually 
the  first  thing  noticed.  A  child  apparently  in 
good  health  will  complain  of  inability  to  walk. 
At  tlie  same  time  there  will  be  an  enlarge- 
ment of  certain  groups  of  muscles.  In  cases 
seen  by  me  the  muscles  of  the  calves  were 
almost  as  large  as  those  of  the  thighs.  Stew- 
art has  reported  cases  in  which  the  calves  of 
the  child  Avere  as  large  as  those  of  an  adult. 
Fig.  273. -Pseudohypertrophic  The  muscles  most  frequently  affected  are  the 
araysis.  deltoids,  biceps,  triceps,  latissimus  dorsi,  and 

I  am  indebted  to  Dr.  Dexter  Ashley  for  the         ,i^ „ „„j.„:-3„ 

above  illustration.  StCmO-maStOldS. 


PSEl'DO-HYPERTROPHIC  PARALYSIS. 


841 


Fig.  274. 


Fig.  275. 


Pseudohypertrophic 
Paralysis. 

Fig.  274. — Note  hyper- 
trophic condition  of  tlie. 
muscles  of  the  legs.  Can- 
not stand  without  strong 
support.     (Original.) 

Fig.  275. — Attempting 
to  rise  from  chair.  Com- 
pare atropliy  of  muscles 
of  arms  and  spine  with 
Iiypcrtrophy  of  muscles  of 
legs.      (Original.) 

Fig.  27G.— Alleinpling 
to  rise  froiii  floor.  Can 
raise  the  body  no  higher. 
(Original.) 


Fig.  270. 


842  DISEASES  OF  TUK   NKKVOl'S  SYSTEM. 

Duclionno  has  found  all  of  the  muscles  of  the  ))odv  hypcrtrophied. 
After  the  hypertrophy  disa])})ears  it  is  succeeded  hy  an  atrophic  condition. 
There  is  less  muscular  irritahility  with  faradic  and  galvanic  currents.  The 
patellar  reflex  is  usually  ahsent  as  the  disease  progresses. 

Cask  T. — A.  L..  (i  years  old,  boy.  As  a  baby  tlie  mother  noted  that  there  was 
something  the  matter.  \\'alked  at  2  years  of  age.  Child  was  very  fat,  and  had  a  good 
appetite  at  that  time.     Now  eats  but  little. 

Walks  very  erect,  in  soldier-like  position,  almost  suggesting  Pott's  disease. 
Steps  slowly.  On  table,  first  noted  apparently  strong  muscular  development  of  the 
back.  Muscles  of  back,  thigh,  calves,  apparently  well-developed.  Child  rises  from 
the  floor  with  characteristic  movements.  Flat-footed.  Cannot  get  up  without  roll- 
ing over,  when  reclining  on  back.  Child  looks  to  be  in  good  health.  Father  says 
he  is  constantly  growing  weaker,  slowly.  Came  to  me  for  diagnosis,  not  having 
previously  known  the  nature  of  the  condition. 

Case  II. — Jacob  S.,  was  first  seen  by  me  when  12  years  old.  Walking  became 
impaired  at  the  age  of  6  years,  gradually  getting  worse,  so  that  to-day  he  cannot 
walk  at  all.  The  reflexes  are  absent.  Sensation  is  impaired.  The  spinal  muscles 
in  dorsal  region  are  atrophied.  Gastrocnemii  markedly  increased  in  size.  The 
extreme  difficulty  of  rising  from  a  sitting  ])Osition  is  very  characteristic.  (Fig.  270). 
The  loss  of  i)ower  in  arms  is  quite  marked  also.  A  history  of  diphtheria  is  given 
just  prior  to  the  onset. 

Dr.  L.  S.  Manson  kindly  referred  this  case  to  me. 

Prognosis. — The  prognosis  as  a  rule  is  had. 

Treatment. — The  treatment  consists  in  restoratives.  Massage  may  he 
tried.  Such  a  case  should  always  he  sent  to  a  neurologist  to  outline  the 
future  course  of  treatment. 

Facial  Paralysis  in  the  New-born. 

This  condition  is  most  frequently  seen  in  the  new-born  after  the  use 
of  the  forceps.     It  is  a  peripheral  paralysis  resulting  from  traumatism.     It 

is  the  result  of  pressure  on  the  nerve  near  the 
exit  through  the  stylo-mastoid  foramen  or  where 
the  facial  nerve  crosses  the  ramus  of  the  jaw. 
The  parotid  gland  gives  little  j^rotection  in  the 
new-born.  The  paralysis  is  most  frequently 
unilateral,  as  usually  only  one  blade  of  the 
forceps  causes  injury. 

Fig.  277.— Facial  Par-  FaclVL     PaHALYSIS     (BkLL's     ParALYSJS). 

alysis    following    Ma.stoid 

Operation.     (Original.)  '^''''•^     '^     fre(|ucntly     called     post-operative 

palsy.     This  disease  may  follow  mastoid  opera- 
tion.     It    may    also    follow    retro])haryngeal    abscess    (Bokai). 

The  disease  is  sometimes  associated  with  tumor  in  the  cerebellum. 
Prognosis  and  Course. — Great  care  should  be  exercised  in  expressing 


ABSCES8  OF  THE  J'.RAIN.  843 

an  O2)inion  as  to  the  outcome  of  a  case  of  facial  palsy.  In  one  case  seen 
by  me  after  a  mastoid  operation  a  permanent  palsy  remained.  I  saw  the 
case  four  years  after  the  operation. 

Treatment. — -This  depends  on  the  cause.  Restorative  treatment  aided 
by  massage  and  electricity  should  be  tried.  Unless  some  improvement"  is 
noted  within  a  few  weeks  the  outcome  of  the  case  will  be  serious. 


Abscess  of  the  Buain  (Cerebr-vl  Abscess). 

This  condition  is  occasionally  seen  in  children. 

Etiology. — There  are  two  principal  causes  of  this  condition :  first, 
traumatism — injury  to  the  head  by  a  blow  or  a  fall,  resulting  in  fracture 
of  the  skull  or  in  abscess ;  second,  from  an  extension  of  middle-ear  abscess 
into  the  mastoid  cells,  so  that  an  abscess  of  the  cerebellum  results.  The 
infection  is  carried  through  the  veins  or  usually  along  the  lateral  sinuses 
to  the  cerebellum.  Wagner  reported  a  case  of  cerebral  abscess  in  which 
thrush  was  believed  to  be  the  cause. 

The  white  substance  of  the  brain  is  usually  affected  in  this  suppura- 
tive process.  It  is  rarely  seen  in  children  under  1  year  of  age,  but  more 
frequently  between  the  ages  of  1  and  10  years.  Out  of  223  cases  reported 
by  Gower,  24  occurred  between  the  ages  of  1  and  9  years.  Korner's  statis- 
tics show  that  out  of  77  cases  of  brain  abscess,  25  were  secondary  to  ear 
disease. 

In  38  cut  of  40  cases,  according  to  Korner,  the  bone  itself  is 
diseased. 

Pathology. — Meyer  reports  a  case  of  abscess  which  occupied  an  entire 
hemisphere.  The  pus  found  is  usually  greenish-yellow.  At  times  the 
abscess  may  be  encysted,  in  which  case  it  is  surrounded  by  a  pyogenic  mem- 
brane. Lalemand  reports  a  case  of  abscess  of  the  brain  in  which  there  was 
an  escape  of  pus  through  the  auditory  meatus.  "The  most  frequent  seat  of 
the  abscess  is,  first,  the  temporo-sphenoidal  lol)e;  secondly,  the  cerebellum- 
thirdly,  the  frontal  lobes.  Other  locations  are  very  rare.  Abscesses  are 
usually  single.     In  size  they  vary  from  that  of  a  cherry  to  an  orange." 

"Abscess  of  the  brain,  as  well  as  meningitis  and  sinus-thrombosis  sec- 
ondary to  otitis,  begin,  as  a  rule,  at  a  point  corresponding  to  that  at  which 
the  inner  surface  of  the  bone  is  attached.  The  roof  of  the  tympanum 
enters  into  the  middle  fossa,  and  the  bony  partition  is  sometimes  as  thin 
as  writing-paper;  it  is  for  this  reason  iliat  disease  of  the  middle  ear  most 
often  causes  al)scess  in  the  temporo-sphenoidal  lobe  which  lies  on  the  fossa. 

The  mastofd  cells  are  separated  from  the  ])osterior  fossa  by  a  thin 
layer  of  bone,  and  hence  abscess,  secondary  to  disease  in  that  region,  is 
often  situated  in  the  cerebelhim.  'I'lie  extension  of  the  disease  to  the  brain 
is  due  to  thrombosis  extending  from  the  diseased  bone,  or  from  the  ear, 


t 


344  DISEASE8    OF    Till-:    NKKVOLS    SYSTEM. 

through  the  veins  ^vhicli  piiTce  tlie  roof  of  the  tyinpanum  ;  only  rarely  is 
there  a  direct  communication  by  a  sui)purating  tract.  In  common  with 
other  forms  of  intracranial  inflammation  due  to  ear  disease,  abscesses  occur 
more  often  on  the  right  than  on  the  left  side.'' 

Symptoms. — If  the  child  is  old  enough  to  complain,  there  will  be 
iK'adathes  described  over  the  affected  area.  Fever  usually  accompanies  this 
condition.  The  temperature  may  rise  to  104:°  or  105°  F.  in  the  beginning, 
although  cases  are  reported  where  the  temperature  remains  normal.  Vom- 
iting usually  accompanies  this  condition.  At  times  in  young  children  there 
are  convulsions,  conui,  opisthotonos,  and  all  symptoms  pointing  to  a  men- 
ingitis. When  distinct  areas  are  affected,  such  as  the.  motor  areas,  then 
l)aralvsis  of  the  extremities  may  take  place.  Optic  neuritis  is  sometimes 
present.  A  choked  disc  can  sometimes  be  made  out  by  an  ophthalmoscopic 
examination.  If  the  bones  of  the  cranium  are  tlnn  tlien  there  is  usually 
marked  tenderness  over  the  region  of  the  al)sce.-s. 

A  foundling,'  eleven  niontlis  old,  was  in  a  fair  condition  when  first  seen  by  the 
foster  parents,  who  later  adopted  him.  This  infant  subsequently  developed  sore  eye.^ 
and  still  later  had  several  bruises  on  the  scalp  w^hich  suppurated.  In  addition 
thereto  he  was .  emaciated  and  showed  t!ie  evidence  of  both  neglect  and  improper 
feeding.  The  infant  with  proper  feeding  and  hygienic  care  developed  into  a  bright 
healthy  boy.  He  attended  school  and  seemed  in  good  healtli  until  his  seventh  year, 
when  ho  sliowed  signs  of  trouble  with  his  head.  Dr.  W.  B.  Chapin,  who  attended  him, 
suspected  caries  of  the  bones  back  of  the  ear. 

Dr.  W.  Freudenthal  was  called  in  consultation  with  Dr.  Chapin  to  see  the  swelling 
behind  the  ear,  which  had  developed  during  the  previous  eight  weeks.  The  swelling 
was  about  the  size  of  a  large  cherry,  there  was  no  pain  on  palpation  and  no  spas- 
modic contractions.  The  swelling  was  located  on  the  side  of  the  head  corresponding 
to  the  upper  lobe  of  the  ear.  It  was  not  reddened  and  fluctuated  on  palpation.  Ex- 
amination of  the  car  showed  no  pathological  condition.  The  drum  membrane  was 
normal.     There  was  no  tenderness  over  the  mastoid. 

After  waiting  some  time  it  was  thought  advisable  to  open  the  abscess.  The 
abscess  was  opened  bj-  Dr.  Freudenthal  with  general  anaesthesia.  Necrotic  tissue 
was  found,  but  the  mastoid  was  intact,  and  it  was  impossible  to  probe  the  ma.stoid 
cells;  liowever  it  was  found  that  a  small  probe  penetrated  in  the  direction  of  the 
frontal  lobe  to  the  depth  of  3  V4  inches.  Pus  oozed  from  tliis  opening.  As  this  was 
evidently  a  ease  of  cerebial  abscess,  the  wound  was  dressed  and  the  further  operative 
prr)cedures  left  to  a  surgeon.  The  temperature  ranged  between  9!)°  and  104'/^°  E- 
The  abscess  was  on  the  right  side  of  the  head.  Convulsions  occurred  on  t'he  left 
side  of  the  body.  Dr.  A.  Cerster  was  called  in  and  diagnosed  the  case  as  a  cerebral 
abscess.  On  the  following  morning  an  operation  w'as  performed.  To  be  sure  that 
the  mastoid  w,;s  not  involved,  part  of  the  mastoid  was  opened.  It  was  found  normal. 
Two  ounces  of  pus  were  evacuated  from  the  abscess.     The  case  ended  fatally. 

Diagnosis. — 'I'liis  's  usually  made  when  su])])uration  of  tlie  middle  ear 
existed  prior  to  this  attack.  If  opisthotonos,  symptoms  of  coma,  convul- 
sions, high  fever,  or  vomiting  follow  an  attack  of  acute  or  sub-acute  otitis, 

'  T  am  indebted  to  Mr.  Saul  .Taplia  fur  the  clinical  history  of  this  foundling. 


IDIOCY    AND    IMBECILITY.  g45 

then  an  extension  of  the  suppurative  process  should  he  suspected.  At  times 
the  diagnosis  will  tax  the  ingenuity  of  the  most  expert  aurist. 

Prognosis. — This  is  always  grave.  Our  only  chance  for  saving  life  is 
to  resort  to  an  early  operation. 

Treatment. — The  eiirlier  surgical  relief  is  instituted,  the  better  will 
be  the  result.  The  medicinal  treatment  corisists  in  relieving  symptoms 
such  as  fever  by  means  of  an  ice  coil,  and  by  active  catharsis.  Eelieve  the 
iicrvous  symptoms  with  the  aid  of  large  doses  of  bromide  and  chloral.  Com- 
plete details  of  brain  surgery  are  given  by  M.  Allan  Starr  in  his  book  on 
"Brain  )Surgery." 

Alalia  Idiopatiiica^  (Backwardness  ix  Speakixo). 

When  a  child  is  in  good  health  and  does  not  leirn  l:ow  to  speak, 
careful  examination  is  necessary.  In  such  cases  it  is  iuiportant  to  exclude 
idiocy.  Although  some  children  do  not  speak  before  they  are  2  or  3  years 
old,  their  general  habits  and  mannerisms  will  easily  show  whether  or  no 
we  are  dealing  with  mental  disease. 

The  prognosis  is  excellent,  although  frequently  parents  will  be  very 
anxious  and  worried  regarding  the  outcome. 

Treatment. — Persistent  teaching  will   usually   remedy   this   condition. 

Idiocy  and  Imbecility. 

In  idiocy  we  have  a  congenital  al)senec  of  mentality  and  intelligence. 

In  iinhecilifij  we  have  an  arrested  development  or  a  partial  arrest  of 
development. 

Etiology. — According  to  Sliuttlewortli  ]>ro!onge(l  labor  without  in- 
strumental interference  is  the  cause  of  idiocy  in  21)  per  cent,  of  cases 
admitted  to  his  asylum.  Down  states  that  of  2000  idiots  examined  by  him 
there  were  symptoms  of  suspected  inanition  at  birth  in  20  per  cent.  This 
writer  also  states  that  d'sturbanee  of  the  mother's  physical  condition  dur- 
ing pregnancy  resulted  in  mentally  deficient  offs})ring  in  al)Out  20  ])CY 
cent.  Griesinger  states  that  "violent  shock  and  grief  during  pregnancy 
appear  not  to  b(»  without  influence  as  a  cause  of  idiocy."  Consanguinity  is 
a  mucli  disputed  po'nt.  Some  authors  l)elieve  tliat  blood  relations  in- 
variably have  mentally  deficient  olTsjiring.  Other  equally  observant  writers 
liold  the  opposite  view.  I  have  seen  a  case  of  idiocy  in  which  the  fatlier 
and  mother  were  first  cousins.  Children  of  intemperate  parents,  and  chil- 
dren of  syphilitic  and  tubercular  parents  are  frequently  found  to  be  men- 
tally deficient. 


'  Read  also,  "Very  Late  Speaking,"  Part  T,  page  3. 


846 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Shiittleworth,  a  well-recognized  English  authority  in  this  field,  gives  the 
following  classification  of  idiocy : — 

Table  No.  104a. 

CLASS    A — CONGENITAL. 

1.  ^licrocephalic. 

2.  Hj'drocephalic     (also    non-congeni- 
tal ) . 

3.  Scrofulous.     "Mongol   type." 

4.  Sensoi'ial    (also  non-congenital). 
.').  I'liniarily  neurotic. 
0.  Paralytic   (also  non-congenital) . 

7.  Choreic    (also  non-congenital). 

8.  Cretinoid:      (a)   sporadic,   (6)    en- 
demic. 

CLASS  B — NON-CONGENITAL. 

(a)  Dcvclopmenial. 
9.  Eclamptic. 

10.  Epileptic. 

11.  Syphilitic. 

12.  Post-febrile  (also  accidental) . 
(b)   Accidental  or  Acquired. 

13.  Toxic. 

14.  Traumatic. 

15.  Emotional. 
IG.  From  mixed  causes. 

Symptoms  and  Diagnosis. — 

Great  care  must  be  taken  in  dif- 
ferentiating between  backward- 
ness and  idiocy.  A  child  that  is 
backward  in  development  does 
not  remain  stationary  in  develop- 
ment, but  progresses  very  slowly 
in  comparison  with  children  of 
the   same   age;    for   example,   a 


Fig.  278 —Congenital  Idiocy  (Lillie  B.).  Age  6 
years.  Deli,  ate  until  4  years  of  age.  Did  not  walk 
until  the  fourth  yi'ar.  Mother  cannot  tell  when 
difference  in  the  two  sides  was  first  noted.  There 
were  no  convulsions.  The  head  measured  19  inches. 
There  were  strahisinus,  and  deformed  jaws.  The 
mouth  was  constantly  oi)en.  Kight  hemiplegia, 
more  marked  in  ujjper  extr  mity.  Walks  and  runs 
around,  but  drags  right  foot.  Contracture  and 
spasticity  i)resent.  Expression  idiotic.  Has  never 
talked.  Intelligence  nil.  Is  restless  and  in  nearly 
constant  motion.    (Case  of  Dr.  A.  C.  Cotton.) 


backward  child  of  5  or  C  years 
will  show  the  mental  development  of  a  child  but  2  or  3  years  old.  In  such 
a  case  we  deal  with  a  slow  mental  progress,  whereas  an  idiot  shows  a  distinct 
arrest  of  development,  both  of  body  and  mind. 

Down  describes  Mongolian  idiocy  in  the  following  language:  "The 
hair  is  not  black  as  in  the  real  Mongol,  but  of  a  brownish  color,  straight 
and  scanty ;  the  face  is  flat  and  broad,  and  destitute  of  prominence ;  the 
cheeks  rounded  and  extended  laterally;  the  eyes  obliquely  placed,  and  the 
internal  canthi  more  than  normally  distant  from  one  another  (the  epi- 
canthic  fold  often  abnormally  large)  ;   the  palpebral  fissure  very  narrow; 


IDIOCY    AND    1M]3P:C1LLTY. 


847 


tlie  foreliead  wrinkled  transversely,  from  the  constant  assistance  which  the 
levatores  palpebrarum  derive  from  the  occipito-frontalis  muscle  in  the 
opening  of  the  eye;  the  lips  large  and  thick,  with  transverse  fissures;  the 
tongue  long,  thick,  and  much  roughened ;  the  nose  small ;  the  skin  has  a 
slightly  dirty,  yellowish  tinge,  and  is  deficient  in  elasticity,  giving  the 
appearance  of  being  too  large  for  the  body. 


Fig.  279. — Imbecile  (Louie  W.).  Showing  an- 
terior curve  of  the  spine  and  general  atrophy  of 
all  the  muscles,  especially  those  of  the  back  and 
shoulders.     (Original.) 


Kig.  280.— Imbecile  (Louie  W.).  Showing 
normal  position  of  head  flexed  on  the  chest. 
Can  only  lilt  head  by  raising  chin  with  exten- 
sor muscles  of  band  and  forearm.     (Original.) 


"This  type  occurs  in  more  than  10  per  cent,  of  cases;  they  are  always 
congenital  idiots;  they  have  considerable  power  of  imitation;  they  are 
humorous;  they  are  usually  able  to  speak,  the  co-ordinating  faculty  is 
abnormal;  the  circulation  is  feel^le;  the  improvement  wliich  training 
effects  is  greatly  in  excess  of  what  would  be  predicated  if  one  did  not 


348  DISEASES    OF    THE    NERVOUS    SYSTEM. 

know  the  characteristics  of  this  type;    the  life-expectancy  is,  however,  far 
below  the  average,  and  the  tendency  is  to  tuberculosis." 

These  children  are  usujilly  i'our.d  to  be  deuf,  blind,  or  to  have  some 
deforniitv  of  the  mouth,  nose,  hands,  or  feet.  I  have  seen  cases  of  this 
kind  in  my  service  at  the  German  Poliklinik,  of  Xew  York,  and  also  re- 


Fig.  281.— Imbecile  (Louie  W.).  Showing  posi-  Fig.   282.— Imbecile  (Louie  W.).       Showing 

tion  Hssumed  in  walking.    Cannot  stand  on  feet  drop  wrist  and  foot.     (Original.) 

(Original.) 

member  seeing  this  form  of  disease  at  the  Children's  Klinik  of  Dr.  Hugo 
Neumann,  at  Berlin.     This  disease  usually  ends  fatally. 

I  allude  to  infantile  amaurotic  idiocy  (on  page  849).  Other  forms 
of  mental  impairment  are  described  in  detail  (see  article  on  "Sporadic 
Cretinism,"  page  760). 


INFANTILE    AMAUROTIC    FAMILY    IDIOCY.  849 

An  Imbecile  Havi>'g  Microcephaly  and  Pseudo-muscular  Atrophy. — Louii- 
W.,  5  years  old,  was  referred  to  me  through  the  courtesy  of  Dr.  L.  S.  Manson. 

Previous  HiHtonj. — This  child  was  born  at  full  term,  natural  labor,  no  forceps. 
He  was  breast-fed  about  15  months;  could  not  stand,  walk  nor  talk  until  2  years  old. 
Dentition  began  during  the  nintli  nujnth,  which  was  very  early  in  this  family,  as  all 
the  other  children  teethed  at  fifteen  months.  He  had  measles  when  2  years  old, 
influenza  and  pneumonia  when  3  years  old.  The  boy  has  an  unusually  small  skull, 
Ki  inches  in  circumference;    the  normal  circumference  at  this  age  is  about  21  inches. 

Family  History. — The  mother  had  been  married  twice,  had  six  children  with  the 
first  hu.sband  and  five  with  the  second.  Three  children  died  of  scarlet  fever.  Tlu' 
rest  of  the  children  are  strong  and  healthy.  There  is  no  family  history  of  idiocy  or 
nervous  disease  on  eitlier  father's  or  mother's  side. 

The  mother  first  noticed  trouble  when  the  child  was  2  years  old,  when  he 
began  to  go  about  on  his  knees,  having  never  walked  on  his  feet.  He  has  no  power 
in  the  hands  or  feet ;  speaks  very  little,  voice  tremulous.  Tic  of  small  muscles  of 
chin;  knee-jerk  both  present.  There -is  great  muscular  weakness  of  the  lower  e.\- 
tremities  and  muscles  of  the  back.  There  was  drop-wrist  and  foot  and  universal 
wasting  of  the  muscular  system  without  marked  trophic  changes.  Noiinal  position  of 
head  is  that  of  flexion  on  chest  and  can  only  lift  head  by  raising  chin  with  extensor 
muscles  of  hand  and  forearm.  Fibrillary  twitching  of  all  the  muscles  in  hands  not 
amounting  to  athetosis. 

IxFAXTiLE  Amaurotic  Family  Idiocy. 

This  peculiar  condition  has  attracted  considerable  attention  in  recent 
years.  In  1881  Tay,  of  England,  described  a  case  of  symmetrical  changes 
in  the  macula  lutea.  The  child  could  not  sit  erect  and  was  backward  men- 
tally. John  Claiborne,  reviewing  this  subject  in  1900,  refers  to  the  above 
case,  and  says  : — 

"At  the  first  examination  the  optic  disc  was  normal,  Init  at  the  macula 
there  was  a  white,  more  or  less  round  area,  in  the  center  of  which  was  a 
brown  spot.  The  picture  Avas  similar  to  that  seen  in  embolism  of  the 
central  artery  of  the  retina.  Tay  at  first  thought  it  was  a  congenital 
cliange.  Five  months  later  he  noticed  the  optic  disc  was  atrophied.  Three 
months  later  he  observed  3  other  cases  in  the  same  family.  In  all  the 
ophthalmoscopic  picture  was  the  same,  and  all  these  persons  died  before 
the  end  of  the  second  year  of  the  disease.  During  the  years  188o  and 
1886  the  same  ophthalmoscopic  picture  was  described  by  Magnus,  Knapp, 
and  others.  In  1887  Sachs  reported  a  case  which  impressed  him  as  being 
one  of  idiocy;  this  was  particularly  interesting  on  account  of  the  changes 
observed  in  the  cortical  cells.  The  family  character  of  the  affection  was 
suggested  to  him  after  observing  4  cases  in  two  families.  Kingden,  of 
England,  published  a  case  and  showed  a  picture  which  eye  surgeons  said 
belonged  to  the  di.sease  which  Sachs  had  elucidated.  In  1898  Sachs  re- 
viewed the  subject,  tabulating  29  cases." 

A.  Jacobi  reported  3  ca.ses  of  this  form  of  idiocy  to  the  American  Ped- 
iatric Society  in  1898. 


,S50  DLSEASlvS    OF    THE    XKRVOIS    SYSTEM. 

Pathology. — Sachs  states  that  the  external  configuration  of  the  brain 
exhibits  a  distinct  picture  of  a  hjwer  order  of  development.  It  is  difhcult 
to  state  whether  the  changes  were  to  be  regarded  as  primary  degenerations 
or  due  to  an  arrest   in   development. 

Symptoms  and  Diagnosis. — ThciH'  is  "a  milky-l)lu('  or  white  optic  disc 
with  bright  cherry-red  center  occupying  the  phice  of  the  macula  lutea." 
Xvstaguius  is  frequently  present.  Hydrocephalus  has  been  reported  asso- 
ciated with  this  condition.  The  weakness  of  the  extremities  increases  slowly 
until  dii)legia  appears.  In  snch  cases  the  optic  sym])toms  and  idiocy  are 
pronounced,  and  from  tlu'se  two  conditiojis  alone  the  diagnosis  can  he 
made.  The  voluntary  mustles  are  relaxed,  especially  those  of  the  ab- 
donu-n.  Death  usually  comes  at  the  end  of  the  second  or  third  year, 
although  the  disease  may  last  years.     The  chihl  is  totally  blind. 

Treatment. — No  treatment  has  as  yet  moditied  or  benefited  these 
children. 

C'OXCISSIOX    OF    THE    BrAIN. 

We  Irequently  see  children  who  have  fallen  down  a  flight  of  stairs,  or 
with  a])pai-ently  as  severe  symptoms,  will  recover.  The  following  case 
illustrates  coucussion  of  a  vi'ilil  h/jir  which  recovered: — 

Case  I. — A  boy,  7  years  old,  lolli'd  down  a  lliylit  of  stairs.  I  saw  him  about 
one  liour  after  liis  fall.  There  was  nausea  and  vomiting.  Some  slight  abrasions  of 
the  skin  were  present,  and  a  scalp  wound  one  inch  in  length  which  required  a  stitch. 
The  temperature  was  10!)°  E.  The  boy  was  put  to  bed.  I  saw  him  about  twelve 
liours  later.  He  was  j)oife<tly  normal  and  complained  of  intense  hunger.  On  the 
following  day  the  boy  was  apparently  well. 

Case  ll.—Sricrc  Connisyiaii  of  the  Bruin.- — Child  S.  was  seen  by  me  through 
the  courtesy  of  Dr.  E.  1).  Lederman,  with  the  following  history:  He  was  in  his  fourth 
year,  bottle-fed  during  infancy,  and  excepting  an  occasional  attack  of  dyspe])sia,  had 
always  cnjftyed  good  health. 

Present  CoiKlitioii. — 'Jliree  days  before  I  saw  him  he  fell  and  struck  his  head 
violently  on  the  i)avciiiciit.  Six  hours  later  severe  vomiting  set  in.  During  the  night 
following  the  fall  he  wiis  feverish  and  moaned  continually.  On  the  following  day 
when  Dr.  Lederman  saw  him  the  temperature  was  103°  F.  The  child  seemed  to  be 
dazed  ami  in  a  stupor  at  times.  He  was  very  thirsty.  There  were  marked  evidences 
of  clonic  and  tonic  spasms  in  the  muscles  of  the  body.  A  laxative  was  ordered.  The 
gastrointestinal  tract  Avas  cleaned  and  an  ice-lmg  applied  to  the  head.  These  same 
symptoms  continm-d,  the  fever  rose  to  10.")°  F.  and  was  not  easily  reduced.  "When  I 
saw  him  in  consnitat  inn  with  Dr.  licderman  there  were  spastic  conditions  of  tlie 
muscles  of  the  aiiii-^  and  legs.  Tlieic  was  marked  rigidity  of  the  spine.  The  stenio- 
cleido-mastoid  muscles  were  rigid.  There  was  marked  opisthotonos.  Severe  photo- 
phol)ia.  The  puj)ils  were  dilated  and  did  not  respond  to  a  strong  light.  The 
Baldnski  reflex  was  present  on  the  right  side,  but  not  so  positive  on  the  left  side. 
When  moved  about  the  child  moaned  as  though  in  pain.  A  tache  cerebrate  was  also 
jiresent.      The  diagnosis  of  concussion   and  traumatic  basilar  meningitis  was  made. 


INSOLATION.  85  j^ 

A  lumbar  puncture  was  made  and  almost  one-half  ounce  of  tiu'bid  (milky)  cerebro- 
spinal lluid  wa.s  wilhdrawn.  The  child  passed  urine  involuntarily  (evidently  due  to 
bladder  paralysis).     The  case  ended  fatally. 

Insolation  (Heat-stkokl:    Sunstroke). 

This  condition  is  most  frequently  seen  in  niidsummer.  It  sometimes 
occurs  in  perfectly  healthy  children  who  are  exposed  to  the  direct  rays  of 
the  mid-day  sun.  I  have  frequently  seen  cases  of  sunstroke  in  feehk  chil- 
dren who  were  playing  in  the  shade.  Children  with  lowered  vitality  and 
convalescents  from  some  severe  illness,  such  as  diphtheria  or  pneumonia, 
are  more  prone  to  be  affected  by  intense  summer  heat. 

Pathology. — Intense  cerebral  hypersemia  and  an  intense  engorgement 
of  the  veins  thr(mghout  the  body  are  the  usual  lesions  seen  in  this  con- 
dition. 

Symptoms. — A  child  in  apparently  good  health  in  niidsummer  will 
suddenly  show  intense  fever.  The  temperature  reaches  as  high  as  10-1° 
or  105°  F.  in  numy  instances.  There  is  a  corresponding  increase  in  the 
pulse-rate.  The  pulse  may  be  as  high  as  IGO  or  180.  The  face  is  usually 
hushed.  The  head  is  hot.  'Jliere  is  a  throl:)bing  of  the  blood-vessels  very 
apparent.  The  child  may  be  unconscious  and  muscular  twitchings  may  be 
noticed.      In  severe   prostration  there   may  be   delirium   and   convulsions. 

The  pupils  are  usually  contracted,  although  they  may  be  dilated,  and 
the  eyes  intensely  congested.  fSometinies  vomiting  and  diarrhoea  may  ac- 
company the  sym})toms  above  mentioned. 

The  following  illustrates  the  manner  in  which  heat-stroke  occurs 
in  New  York  City  :— 

A  child  will  awaken  in  a  normal  condition,  eat  its  breakfast  and  play  as  usual. 
After  several  hours  hard  playing  and  exposure  to  the  sim's  rays,  the  chihl  will  be 
exhausted.  If  a  careless  mother  or  nurse  permits  the  child  to  continue  its  exposure 
to  the  direct  midsummer  heat,  then  pro.stration  with  the  above  noted  symptoms  will 
be  noticed.  In  some  cases  brought  to  my  clinic,  the  head  is  hot  and  the  hands  an  I 
feet  are  cold.  If  the  sunstroke  takes  place  soon  after  feeding,  then  violent  gastric 
symptoms  usually  occur. 

Prognosis. — The  prognosis  depends  upon  the  vitality  at  the  time  of 
sunstroke.  We  must  differentiate  this  condition  from  meningitis.  The 
suddenness  of  the  attack  following  exposure  to  the  sun  will  usually  aid 
in  making  a  diagnosis.  'Hie  majority  of  cases  seen  by  me  recovered.  Occa- 
sionally a  fatal  case  was  encountered,  especially  in  bottle-fed  infants. 

This  infant  (Fig.  28:V)  brouglit  to  my  clinic  July.  1000,  weighed  5  pounds  (i 
ounces.  He  was  a  bottle-fed  infant,  reared  on  condensed  milk.  He  was  nine  weeks 
old.  Vomited  after  each  feeding,  had  greenish  nnicous,  sour  smelling  stools,  every 
half  hour  and  oftener.  There  was  eczema  between  the  thighs  from  excoriation  and 
acid  stools.    The  child  weighed  G  Vj  pounds  at  birth,  and  was  a  full-term  baby. 


852 


DISEASES    OF    THE    NERVOl  S    SYSTE.AI. 


The  cliild  was  pulseless.  The  extreinitios  were  cold  and  covered  with  a  clammy 
perspiration.  The  temperature  was  subnormal — 97°  F.  Tlie  fontanel  was  de- 
pressed. The  heart  sounds  were  barely  audible.  The  mouth,  tongue,  and  lips  were 
very  dry;  food  and  water  were  refused.  Spirits  of  camphor,  5  drops,  was  injected 
hypodermically ;  a  mustard  foot-bath  was  ordered.  The  child  died  fifteen  minutes 
later. 


Fig.  283. — Insolation  (Heat  Stroke).     Type  of  mid-summer  cases  in  New 
York  City.      (Original.) 

Diagnosis. — Cholera  infantum,  marasmus,  due  to  malassimilation  of  food;  im- 
proper food  to  commence  with.  Extreme  heat  caused  heart  failure  and  general  pros- 
tratiofi. 

Treatment. — A  tub-lmtli,  tt'ni])cratuvo  90°  F.,  gradually  decreased  to 
70°  F.,  duration  five  iniiuites,  is  advisal)le.  An  ice-bag  should  be  applied 
lo  the  head.  If  consciousness  has  been  restored,  the  child  should  be  al- 
lowed to  rest ;  if  not,  tlien  we  can  restore  the  circulation  to  relieve  cerebral 
hyperaemia  by  giving  a  mustard  foot-bath  for  several  minutes  until  the  skin 
is  reddened.     The  rectum  and  colon  should  be  flushed  with  a  hot  saline 


INSOLATION.  853 

solution  at  a  temperature  of  110°  F. ;    this  will  stimulate  diuresis  besides 
cleansing  the  bowel.     One-drop  doses  of  aromatic  spirits  of  ammonia  with 
water  may  be  given  every  15  minutes. 
If  the  child  can   swallow   then: — 

3  Bromide  of  sodium 10  grains 

C'liloral  hydrate • 3  grains 

should  be  given  to  a  child  5  years  old.  This  can  be  repeated  every  hour 
until  a  sedative  effect  is  produced.  In  some  cases  (comatose)  it  may  be 
advisable  to  inject  per  rectum : — 

IJ  Bromide   of   sodium 15  grains 

Starch   water 1  ounce 

Cold  water  should  be  given  by  mouth,  with  several  drops  of  diluted 
hydrocliloric  acid.  Peptonized  milk,  thin  soups,  and  broths  may  be  given 
every  few  hours.     Liquid  peptouoids  can  be  tried  if  food  is  rejected. 


PART  X. 

DISEASES  OF  THE  EAR,  EYE,  SKIN,  AND  ABNORMAL 

GROWTHS. 


CHAPTER  1. 
DISEASES  OF  THE  EAR. 

Acute  Catarrhal  Otitis  Media. 

Acute  catarrlial  otitis  media  arises  in  the  great  majority  of  cases  from 
extension  of  an  infiammator}'  process  by  way  of  the  Eustachian  tube. 

Etiology. — Burkens  found  10-i  deaths  in  33,107  ear  cases,  and  Eandall 
13  in  5(JUU,  giving  a  percentage  of  three-tenths  of  1  per  cent,  from  intra- 
cranial disease. 

Schwartz  records  30  deaths  in  8435  ear  cases,  or  0.35  per  cent.  The 
death  rate  from  purulent  ear  diseases,  compared  witli  all  other  diseases 
treated,  was  sliown  in  Guy's  Hospital,  in  London,  some  years  ago,  to  be 
57  deaths  among  9000,  two-thirds  of  1  per  cent;  40,073  autopsies  in  the 
Vienna  General  Hospital  showed  232  deatlis  from  otitic  eom])Iieations,  i.e., 
0.58  per  cent.  The  majority  of  these  deatlis  occurred  in  tlie  course  of 
clironic  suppuration  of  the  middle  ear,  complications  in  the  acute  stage, 
with  the  exception  of  mastoiditis,  being  less  frequent. 

Naso-pharyngeal  disease,  especially  the  infectious  diseases,  such  as 
measles,  scarlet  fever,  influenza,  and  diphtheria,  are  J'requently  fol- 
lowed by  otitis.  The  ease  with  which  ])athogenic  bacteria  can  cause  an 
inflammatory  extension  from  the  nose  into  the  Eustaqhian  tube  is  now 
recognized.  Children  of  the  lymphatic  and  rachitic  types  are  more  sus- 
ceptible to  these  infections. 

When  a  catarrhal  process  limits  its  attack  to  the  lower  portion  of  the 
middle  ear  chamber,  the  disease  may  run  its  course  without  becoming 
purulent.  When,  however,  the  u))])('r  pai't  or  tym])anic  attic  is  involved, 
we  are  more  apt  to  find  that  the  infection  assumes  a  suppurative  type.  It 
is  in  this  class  of  cases  that  complications  arise  aiul  extension  to  the  mas- 
toid cells  by  way  of  the  aditus  soon  follows. 

Bacteriology. — Observers  have  found  that  even  in  the  normal  tym- 
panic cavity,  ])athogenic  l)acteria  exist.  Consequently  any  deviation  from 
the  normal  process  in  this  region  predisposes  the  individual  to  a  purulent 
infection.  A  ])assive  congestion  of  the  tvmpanic  mucous  membrane  due  to 
(854) 


PLATE  XXVIII 


Normal  silicons  Membrane  of  the  Middle  Ear  in  the  New-born. 


'^'J 


IclM 


^■^•O 


Inflammation  of  the  ^Mucous  Membrane  of  the  Middle  Ear. 
Section  of  infiltration  with  polypoid  excrescences. 


«'.c;>?S'&\'< 


••V.; 


-X  V 


'/"' 


'h 


Section  of  the  Vessel  of  the  Mucous  Membrane  Containing  Streptococcus 
Pyogenes.      (After  S.  Weiss.) 


ACUTE    CATARRHAL    OTITIS    MEDIA. 


855 


cardiac,  renal,  naso,  or  naso-ijharyngeal  disease,  must  be  considered  a 
jDotent  factor  in  the  production  of  a  suj)purative  otitis.  Stapliylococci, 
diplococci,  and  streptococci  have  been  found  in  the  naso-pharyngeal  space, 
and  it  is  reasonable  to  suppose  that  these  micro-organisms  are  apt  to  find 
their  way  into  the  Eustachian  tube  and  tympanitic  cavity  even  under  nor- 
mal conditions. 


Fig.  284. — Complication  of  Scarlet  Fever  seen  in  my  service  at  Riverside  Hospital. 

( Orjorinal.  i 


A  study  of  this  case,  in  which  both  ears  were  discharging,  is  interesting.  Tlic 
temperature  was  only  99  -/^°  F.  in  the  rectum.  This  proves  that  we  must  always  be 
on  the  lookout  for  suppuration  of  tlie  middle  ear  in  the  acute  infectious  diseases. 

Pathology. — We  imi>t  In-ar  in  mind  that  the  ossicular  rhain  is  sur- 
rounded or  enveloped  by  folds  of  mucous  membrane,  and  when  this  tissue 
becomes  engorged  drainage  from  the  attic  is  difficult.  Consequently  our 
incisions  througji  tlie  \\\)\)vr  and  ])osterior  portion  of  the  membrane  in  acute 
otitis  should  be  dclibcrnie  and  somcwliat  hci'oic,  otlierwisc  we  will  not 
accomplish  the  object  in  view,  i.e.,  drainage  from  tliat  portion  of  the  middle 
ear  which  is  most  likely  to  be  followed  l)y  disease  of  the  mastoid  antrum 
and  cells. 

Symptoms. — Two  prominent  symptoms  are  always  present;  one  is 
pain  and  the  other  fever.  The  infant  is  usually  very  restless,  rolling  the 
head  from  side  to  side  on  the  pillow  and  rubbing  the  hand  over  the  affected 


856  Dlh^EASES    ()F    THE    EAR. 

ear.  At  times  the  nose  and  throat  will  also  be  inflamed.  Local  tenderness 
can  usually  be  made  out  on  pressure.  The  examination  of  the  middle  ear 
with  the  speculum  should  always  be  made  by  one  skilled  in  tliis  work.  ^ 

Symptoms  of  meningitis  are  frequently  present  and  will  disappear 
when  proper  treatment  for  an  otitis  is  instituted.  I  have  frequently  seen 
a  case  of  persistent  high  fever,  during  the  course  of  a  scarlet  fever,  suddenly 
improve  after  the  drum-membrane  was  incised.  The  temperature  ranges 
between  100°  and  105°  F.  A  distinct  rise  of  temperature  does  not  always 
accompany  this  condition  as  is  usual  in  other  inflammatory  conditions. 

Diagnosis. — This  is  easily  made  by  one  skilled  in  examining  the  ears. 
When  a  doubt  exists  the  safer  plan  is  to  call  in  an  aurist  for  an  opinion. 
The  neglect  of  this  precaution  may  prove  a  serious  matter,  as  deafness  may 
follow. 

Prognosis. — The  prognosis  is  reasonably  good. 
We  must  not  be  too  positive  in  giving  a  good  prog- 
nosis, as  sometimes  fatal  results  follow  the  extension 
of  the  inflammatory  condition  from  the  middle  ear 
into  the  brain. 

Treatment. — Prompt  drainage  by  an  early  inci- 
sion through  the  bulging  membrane  is  the  treatment 
indicated.  'J"o  further  drainage  under  such  condi- 
tions it  is  wise  to  douche  the  ear  with  hot  antiseptic 
solutions  at  a  temperature  of  108°  to  120°  F.,  using 
a  return  flow  cannula.  It  has  been  claimed  that  the 
higher  the  temperature  of  the  douche,  the  greater 

the   possibilitv  of   al)sorbino-  the  threatening  nias- 
Fig.  285.— Ear  8vringo.  _  / .  *  '=' 

toiditis. 

Prophylactic  Treatment. — As  a  soothing  and  prophylactic  agent  after 
incision  or  even  before  surgical  intervention  is  indicated,  a  carbolized  glyc- 
erine solution  acts  Avell  in  a  number  of  these  cases.  In  a  very  young- 
child  a  2  per  cent,  solution  may  be  instilled  into  the  ear  after  the  same  has 
l)een  cleansed  with  a  douche,  every  two  hours.  This  may  be  increased  in 
strength  as  the  age  of  the  patient  progresses.  Oily  combinations  should 
never  be  used  as  local  agents  in  aural  disease.  They  are  apt  to  become 
rancid,  and  as  the  middle  ear  is  an  excellent  incubator,  affording  bacteria, 
plenty  of  heat  and  moisture,  infection  rapidly  occurs. 

General  Treatment. — Peroxide  of  hydrogen  or  dioxygen  is  a  valuable 
cleanser  and  deodorizer  when  the  perforation  of  the  membrane  is  large. 
The  same  remedy  may  cause  extension  of  a  purulent  otitis  if  the  aperture 
in  the  drum  is  small,  and  the  liberation  of  its  oxygen  causes  sufficient 
pressure  to  force  the  ])uru]ent  foci  backward  through  the  aditus.  Bulging 
of  the  upper  portion  of  the  mendDrane  with  a  protrusion  of  the  superior 
and  posterior  walls  of  the  external  auditory  meatus,  together  with  tender- 


ACUTE    CATARRHAL    OTITIS    MEDIA.  857 

ness  over  the  mastoid  autruiii  or  tip,  witli  some  elevation  of  temperature, 
occurring  during  the  course  of  an  acute  otitis,  are  indicative  symptoms  of 
mastoid  involvement.  Extensive  disease  of  the  mastoid  cells  may  exist 
without  the  slightest  rise  in  temperature,  especially  if  the  acute  stage  of 
the  inflamnuitory  process  has  passed  by. 

We  may  safely  assume  that  in  all  cases  of  catarrhal  otitis  the  mucous 
membrane  lining  the  mastoid  antrum  is  involved  simultaneously  with  that 
of  the  middle  ear,  as  it  is  part  of  the  same  tissue.  For  this  reason  blood- 
letting, done  under  aseptic  precautions,  should  be  carried  out  as  near  the 
cavity  as  possible;  therefore,  an  internal  Wilde's  incision  carried  through 
tlie  posterior  suj^erior  quadrant  of  the  membrane  is  certainly  a  rational 
procedure. 

Eestorative  treatment  such  as  iron,  codliver-oil.  Fowler's  solution,  be- 
sides concentrated  foods,  must  be  remembered.  Unless  we  assist  the  nu- 
trition of  the  body  we  cannot  expect  to  cure  the  disease.  If  the  symptoms 
increase  in  severity  and  the  temperature  persists,  the  dangers  associated 
with  mastoiditis  must  be  remembered,  and  the  skill  of  an  otologist  or  a 
surgeon  will  be  required. 

Mastoid  Operation  ox  Ixfaxts  axd  Children. 

Tn  operating  on  infants  and  children  it  is  important  to  remember  cer- 
tain points  wherein  they  differ  from  adults.  These  briefly  mentioned  are 
the  following:— 

At  birth,  in  the  mastoid  the  antrum  exists  as  the  only  cavity,  about 
the  size  of  a  small  pea ;  the  process  is  not  formed  until  after  the  end  of 
the  first  year,  and  the  pneumatic  spaces  not  until  puberty. 

There  are  also  frequently  dehiscences  filled  with  fibro-cartilage  as  the 
squamo-mastoid  suture  is  not  ossified  at  birth.  So  when  making  the  pri- 
mary incision,  the  knife  must  be  used  gently  until  the  periosteum  is 
reached,  and  this  likewise  must  l)C  raised  with  the  greatest  care  to  prevent, 
in  such  cases,  the  instruments  sli})ping  into  the  cranial  cavity. 

In  curetting  after  opening  the  mastoid,  it  nnist  be  borne  in  mind  that 
the  bone  tissue  in  childhood  is  soft,  so  that  healthy  tissue  need  not  be 
sacrificed  unnecessarily. 

The  Operation. — During  the  operation,  strict  antisepsis  must  be  ob- 
served. The  space  around  tlie  mastoid  for  two  or  three  inches  beyond 
should  be  shaved  and  made  surgically  clean.  The  auditory  canal  should 
1)0  irrigated  with  a  l)ichlnride  solution  of  I  to  1000.  Then  under  com- 
plete aufRslhesia,  with  a  scalpel,  curvilinear  incision  should  be  made  from 
end  of  the  mastoid  close  to  the  insertion  of  the  auricle  to  about  one-half 
inch  of  its  upper  border,  down  to  the  periosteum,     'i'his  is  Ihen  separated. 

The  bleeding  is  controlled  either  by  claniping  vessels,  or  with  gauze 
wrung  out  of  hot  water.     An  Alli)ort  retractor  or  one  of  its  modifications 


868  DISEASES  OF  THE  EAR. 

should  then  l)e  used,  \vhicli  not  only  an>;\vers  the  purpose  of  its  name,  Init 
also  stops  the  oozing.  The  parts  should  be  separated  with  the  auricle 
held  forward  so  that  the  posterior  and  superior  walls  of  the  auditory  canal 
and  the  whole  licld  of  operation  is  exposed  to  view. 

If  the  bone  is  l)athed  in  pus  this  is  wiped  away  and  any  perforation 
is  examined  with  a  i)r()be.  The  ojjening  is  enlarged,  either  with  a  spoon 
or  rongeur.  Should  no  })erl'oration  or  sinus  exist,  then  the  anti-um  sliouM 
be  oi)ened  either  with  a  fiat  chisel  or  gouge  and  a  mallet.  The  supra- 
meatal  triangle  is  above  the  antrum.  This  is  made  by  drawing  one  line 
horizontally  with  the  superior  border  of  the  auditory  cuial,  a  second  ver- 
tical one  with  the  posterior,  and  a  Ijase  line  corresponding  with  the  curvi- 
linear line  between  these  points. 

The  chisel  should  be  used  gently  and  tangential,  and  the  bone  chipped 
away  in  small  sections,  always  working  downward,  forward,  and  inward. 
A  probe  should  be  used  to  determine  from  time  to  time  whether  the  antrum 
has  been  entered,  and  also  to  examine  the  cavity  nuide. 

As  soon  as  an  opening  has  been  made,  a  rongeur  should  be  used  to 
enlarge  it,  and  then  thoroughly  cleaned  out  with  a  Volkman's  spoon.  The 
space  leading  from  the  antrum  to  the  roof  of  the  tympanum,  that  is,  the 
aditus  and  attic,  should  be  carefully  cleaned  out  with  a  small  curette.  Tiie 
antrum  should  then  be  carefully  extended  backward  until  the  lateral  sinus 
is  exposed  and  inspected  as  to  whether  its  appearance  is  healthy.  Its  pres- 
ence can  be  determined  by  its  bluish  appearance  and  the  soft  feel  to  the 
probe.  All  granulations  and  soft  tissue  having  been  cleaned  out,  the  parts 
are  gently  irrigated  with  a  bichloride  solution  of  1  to  5U00,  normal  salt 
solution,  saturated  solution  of  boric  acid,  or  sterile  water  if  considered 
necessary.  The  wound  is  then  wiped  dry,  the  upper  and  lower  ends  can  be 
stitched  together,  and  the  rest  packed  somewhat  lightly  with  iodoform 
gauze.  Bury  this  gauze;  that  is,  do  not  let  it  project;  then  over  this 
draw  the  parts  together  and  apply  layers  of  sterile  gauze,  absorbent  cotton, 
and  a  bandage. 

After-treatment. — Unless  pain  or  a  rise  in  temperature  occurs,  it  is 
frequently  not  necessary  to  change  the  dressing  for  five  or  six  days.  Usually 
there  is  no  discharge  in  the  auditory  canal;  if  there  is,  it  is  gently  irrigated 
or  wiped  out.  For  the  mastoid  wound,  a  dry  wiping  is  all  that  is  neces- 
sary usually,  and  a  dressing  of  sterile  gauze  used  lightly  packed.  This  can ' 
be  changed  every  two  or  three  days.  Granulation  tissue  of  course  must  be 
cauterized. 

Accidents  During  the  Operation. — Wounding  the  lateral  sinus  may 
cause  a  profuse  haemorrhage.  If  the  bony  cortex  has  been  sufficiently  re- 
moved, the  sinus  may  be  plugged  with  iodoform  gauze  and  the  operation 
completed.  The  sinus  whenever  exposed  should  be  kept  covered  with  iodo- 
form gauze  separate  from  the  rest  of  the  cavity  to  prevent  infection.     If 


ACUTE    CATARRHAL    OTITIS    MEDIA. 


859 


tlie  vessel  should  not  be  suffiek'ntly  freed  from  the  bony  covering,  the 
bleeding  may  prevent  the  completion  of  the  operation. 

Exposure  of  the  Dura.—Ji  carefully  dealt  with,  this  is  not  a  matter 
of  much  importance,  if  the  part  is  kept  covered  with  iodoform  gauze  inde- 
pendent of  the  rest  of  the  wound.  If  the  dura  should  Ije  wounded  it  should 
be  opened,  cleaned,  and  sewed  up  with  fine  catgut  sutures. 

Facial  Paralysis. — In  operating,  this  condition  can  be  prevented  bv 
not   interfering   with  the   lower   two-thirds   of   the   posterior   wall   of   the 


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Fig.  286. — A  Common  Type  of  Acute  Mastoid  Inflammation  Following 
Influenza.  There  was  a  double  otitis  before  the  extension  to  the  mastoid 
cells.  Note  the  fever  curve  following  the  operations.  Case  recovered. 
(Oiiginal.) 


auditory  canal  and  the  facial  nerve  will  escape  injury.  Where  it  has  been 
slightly  injured,  the  function  of  the  nerve  is  usually  restored  within  four 
to  six  weeks. 

Francis  M.  C,  1  year  old,  suffered  with  gastric  disturbance,  poor  appetite  and 
syinptoms  resembling  colic.  His  bowels  moved  sluggishly,  the  stool  was  greenish  and 
contained  mucus  and  undigested  particles  of  casein.  He  emaciated  owing  to  the 
non-assimilation  of  food.  From  the  history  I  learned,  that  the  child  has  had  fever 
accompanied  by  catarrh  of  the  nose  and  a  general  bronchitis  for  the  last  four  weeks. 
The  examination  of  the  body  showed  a  decidedly  racliitic  thorax  and  distended 
abdomen:  retarded  dentition  and  general  backwardness  in  development.  There  was 
no  evidence  of  pulmonary  disease.  The  heart-sounds  were  feeble  and  a  hfemic 
murmiu'  was  distinctly  heard  at  the  apex  of  the  heart  and  also  in  the  vessels  of  the 
neck.  Tlie  child  perspired  very  freely.  The  temperature  was  102.4°  F.,  piilse  140, 
respiration  28.  The  throat  showed  enlarged  tonsils  and  also  adenoid  vegetations. 
This  latter  condition  was  reported  by  Dr.  Charles  D.  Manson.  nolh  ears  were  dis- 
charging. The  child  was  very  restless,  moaned  and  fretted  continually  and  did  not 
sleep  at  night.  My  diagnosis  was  influenza,  subacute  gastric  catarrh,  rachitis,  and 
mastoid  involvement.      Dr.  Edward  Dench  saw  this  case  at  my  reiiuest  and  corrobor- 


860  DISEASES    OF    THE    EAR. 

ated  the  diagnosis.  The  temperatiire  rose  to  103.6°  F.  The  right  mastoid  was 
opened  by  Dr.  Deneh  at  the  New  York  Ear  and  Eye  Infirmary.  The  temperature 
tame  down  by  lysis  to  noniial.  Three  days  later,  while  the  child  was  doing  quite  well, 
the  temperature  again  rose  to  103.G°  F.  A  left  mastoid  was  suspected,  and  accordingly 
the  second  operation  was  perfonncd.  On  the  da}'  following  the  operation  the  tempera- 
ture rose  to  104.2°  F.,  and  an  acute  milk  infection  was  suspected.  With  the  aid  of 
mist,  rliei  et  sodii  and  a  diet  of  whey  only,  at  intervals  of  three  or  four  hours,  the 
stomach  symptoms  subsided,  and  four  days  later  the  child  was  removed  from  the 
hospital  to  its  home  in  a  normal  condition.  With  careful  asepsis  both  wounds  healed. 
The  child  gained  in  weight  and  within  one  month  had  entirely  recovered. 

Foreign  Bodies  in  the  Ear. 
Insects,  bugs,  cotton,  beads,  and  pieces  of  pencil  are  frequently  found 
in  the  meatus.  When  beans  or  peas  remain  they  swell  and  cause  painful 
pressure  symptoms.  The  specialist  should  invariably  be  consulted  rather 
than  risk  the  danger  of  traumatism  in  unsuccessful  attempts  at  removal. 
If  a  live  insect  or  bug  is  in  the  middle  ear,  pour  water,  oil,  or  alcohol  into 
tiie  ear.  If  the  insect  is  not  dislodged  by  this  means  try  Allen's  foreign 
body  forceps. 

Thrombosis  of  Cerebral  Sinuses. 

There  are  two  conditions  usually  seen  in  children;  first,  primary, 
wliere  there  is  a  general  malassimilation  of  food,  such  as  we  find  in  ina- 
rasmus.  This  is  also  called  marasmic  thrombosis.  Second,  a  secondary 
condition  due  to  a  local  disease,  such  as  injury  to  tlie  'bone  or  ear. 

rririinrij   thronihosis  is   confined   to   the   superior   longitudinal   sinus. 

Symptoms. — (J^^dema  of  the  scalp  on  the  side  of  the  head  and  fore- 
head. At  times  there  is  epistaxis.  The  fontanel  is  usually  bulging  or 
distended.  If  the  clot  extends  into  the  internal  jugular  then  the  external 
jugular  will  be  overfull  and  the  thromboid  vein  can  be  felt  as  a  very  hard 
band. 

Secondary  Thromhos'is. — This  is  usually  due  to  suppurative  otitis 
media.  It  usually  affects  the  lateral  sinus.  It  may  also  follow  suppuration 
in  tlic  eyes  or  nose,  or  follow  erysipelas. 

Cavernous  sinus  may  result  from  the  lateral  or  petrosal  sinuses.  It 
)nay  be  due  to  extension  from  the  ophthalmic  veins,  such  as  is  found  in 
phlegmonous  inflammation  within  the  orbit. 

"^I'lie  s])ecial  symptoms  are  exophthalmia,  ptosis,  cedema  of  the  lids 
and  of  the  root  of  the  nose,  also  paralysis  of  the  sixth  and  other  ocular 
nerves. 

Thrombosis  of  the  veiufi  of  Galen,  leading  to  effusion  into  the  ven- 
tricles, has  occurred  as  a  fatal  complication  of  scarlet  fever.  "The  throm- 
bosis may  be  brought  about  by  direct  extension  from  the  inflamed  bone,  or 
by  extension  by  accretion  of  a  septic  clot  from  the  veins  of  the  mastoid 
cells,  which  open  into  the  lateral  sinus." 


CHAPTER  II. 
DISEASES  OF  THE  EYE.' 

Acute  Catakriial  Conjunctivitis. 

This  condition  is  usually  associated  with  infections  diseases.  As  a 
rule  it  is  found  in  coryza,  the  acute  exanthemata,  influenza,  and  the  usual 
infections  due  to  pathogenic  bacteria  in  the  atmosphere. 

Genera]  Plan  of  Cleaning  the  Eye  lolien  Secretion  Exists. — The  eyes 
should  be  thoroughly  cleansed  with  a  pledget  of  cotton  dipped  in  lukewarm 
water.     Then  use  a  drop  or  two  of  a  solution  of  cocaiiie: — 

IJ  Cocaine  hydrochlorate  10  grains 

SaHeylie  acid    V2  grain 

Distilled  water  1  ounce 

M.     Drop  into  llie  eye  3  times  a  day. 

After  instilling  the  cocaine,  a  few  drops  of  a  2  per  cent,  argyrol 
solution  should  he  dropped  on  the  eyelid.  The  irritating  secretions 
should  be  wiped  away  as  frequently  as  ])ossible.  A  weak  solution  of  bichlo- 
ride of  mercury,  1  to  5000,  applied  on  cotton,  will  best  serve  to  cleanse  the 
eye.     It  should  be  used  at  a  temperature  of  100°  F.,  hourly  if  necessary. 

A  solut'on  of  borax : — 

IJ  Biborate  of  soda 4  parts 

Distilled  water 100  parts 

Or:— 

IJ  Argyrol    1  part 

Distilled  water 100  parts 

are  very  good  cleansing  remedies. 

Peroxide  of  hydrogen,-  one-half  strengtli,  is  recommended  by  Stephen- 
son, to  bo  used  three  times  a  day. 

Atropia  is  simply  mentioned  to  be  condemned.  Protargol  and  largin 
stain  the  conjunctiva  and   are  useless.     To  pre\ent   the  lids  from  gluing 


'The  correction  of  Errors  of  Refraction,  such  as  astigmatism  by  means  of  eye- 
glasses, and  the  treatment  of  strabismus,  should  only  be  undertaken  by  the  sjjecialist. 
Tlie  reader  is  refeired  to  special  works  on  Diseases  of  the  Eye  for  particulars  regard- 
ing these  conditions. 

^A  good  preparation  on  the  market  is  called  dioxygen. 

(sr,i) 


862  DISEASES  OF  THE   EYE. 

together  the  j^llow  oxide  of  mcrein-v  ointment  sliould  be  applied  two  or 
three  times  a  day : — 

IJ   Yellow  oxiilo  of  nieicury  (5  per  eent.) 1  part 

\^a.seline   10  parts 

Lanoline  10  parts 


Pink  Eyi:. 

This  form  of  acute  ophthalmia  s  simihir  to  the  one  just  described.  It 
is  very  c-ommunieal)k'  and  most  probably  transmits  infection  by  a  specific 
organism. 

"Weelcs^  was  tlie  first  to  descril)e  a  definite  micro-organism  causing 
this  disease.  The  Weeks  bacillus  is  short  and  has  rounded  ends.  It 
stains  very  easily  with  methylene  ])lue.  It  is  intensely  contagious  and 
spreads  rapidly,  especially  in  schools.  Children  under  fifteen  years  are 
especially  susceptible. 

The  diplo-hacilhts  of  j\Iora.r  was  described  by  him  in  June,  1896,  in 
the  Annal  de  I'lnstitut  Pasteur.  The  inflammation  is  frequently  due  to 
the  presence  of  the  diplo-bacilli.  The  inflammation  usually  begins  in  one 
eye  and  infects  the  other  a  few  days  later.  Its  course  may  be  either  chronic 
or  acute. 

PxEiiiococcrs  Ophthalmia. 

'J'his  disease  is  frequently  seen  in  new-born  children  in  which  the 
lachrymal  sac  suffers. 

Griff'ord-  described  an  epidemic  in  Omaha  whore  several  distinct  out- 
breaks took  place  within  a  few  years. 

Veasey*  states  that  the  pneumococcus  is  the  most  frequent  cause  of 
ophthalmia  in  Philadelphia.  The  bacteriological  examinations  of  the  or- 
ganisms are  very  easily  made.  A  cover  glass  smeared  with  the  pus,  stains 
well  with  methylene  blue.  Under  the  microscope  there  are  diplococci, 
cocci,  and  chains  devoid  of  capsule. 

Infection  of  the  conjunctiva  sometimes  occurs.  This  is  frequently 
the  result  of  impetigo  contagiosa  of  the  face  or  scalp.  Infected  secre- 
tions transmitted  to  the  eye  by  the  fingers  usually  set  up  this  inflamma- 
tion. Little  girls  frequently  transmit  vaginal  discharges  on  their  fingers 
and  thus  cause  infection.  The  common  cocci  of  suppuration,  namely,  sta- 
phylococcus pyogenes  aureus,  albus,  and  citrous,  are  usually  found  in  this 
discharge. 


'  Archives  of  Ophthalmology,  1886,  No.  4,  p.  441. 

-Cirifford:      Archives  of  Ophthalnioloor^',  vol.  xxv,  189G,  p.  314. 

'Veasey:     Archives  of  Ophthalmology,  vol.  xxxviii,  1899,  p.  301. 


MEMBRANOUS    CONJUNCTIVITIS.  863 

Treatment. — Clean  the  eye  by  dipping  i^mall  pledgets  of  absorbent  cot- 
ton into  lukewarm  water,  or  dip  the  cotton  into  a  2  per  cent,  solution 
oi'  borax.  A  medicine  dropper  can  be  filled  three  or  four  times  with  a 
solution  of : — 

I^  Formalin  ^  1  to  2000 

Sig. :      Wash  or  bathe  the  eye  with  tliis  f onnalin  solution  every  four  hours. 

Very  hot  water  applied  on  pledgets  of  sterilized  cheese-cloth  will  re- 
duce the  inflammation  of  the  lids.  In  other  cases,  cold  lead  and  opium 
wash  Avill  be  very  soothing  and  have  a  similar  effect.  We  can  prevent  the 
lids  from  sticking  together  by  applying  vaseline  at  night. 

Purulent  Opiitiix\.lmia  (Ophthalmia  Xeoxatorum). 

This  is  a  purulent  conjunctivitis  of  the  new-born  infant.  It  may  be 
seen  several  hours,  or  sometimes  appears  several  days,  after  birth.  The 
amount  of  pus  secreted  is  very  large.  When  the  lids  are  separated  pus 
will  he  liberated. 

Etiology. — Jt  is  usually  caused  by  an  infection  in  the  maternal  pas- 
sages containing  the  gonococcus  during  labor.  The  pneumococcus  has  also 
been  found  in  some  cases.  These  pathogenic  bacteria  are  carried  directly 
into  the  eye,  either  by  the  secretions  or  by  means  of  infected  sponges  or 
towels.  Bacteriology  has  proven  that  all  causes  excepting  distinct  germ 
infection  must  be  eradicated. 

Symptoms. — The  lids  appear  red  and  swollen.  The  upper  lid  fre- 
quently overhangs  the  lower  and  the  infant  is  unable  to  open  the  eyes. 
Stephenson  states  that  10  per  cent,  of  children  so  affected  remain  totally 
blind.  Of  446  cases  of  ophthalmia  occurring  in  the  practice  of  seven  phy- 
sicians quoted  by  Stephenson,  gonococci  was  found  in  72.83  per  cent.  In 
Stephenson's  own  cases,  out  of  45  affected,  30  showed  evidence  of  the  gono- 
cocci, or  (if).")  ])er  cent. 

Preventive  Treatment. — The  C'rede  method  is  now  univei'sally  used. 
As  soon  as  the  infant  is  born  and  the  face  wiped  clean,  the  following  solu- 
tion is  dropped  into  the  eye: — 

IJ  Nitrate  of  silver  solution 2  per  cent. 

Sig.:  It  is  best  to  let  it  fall  from  a  ine<lieine  dropper  on  the  eyebjall.  A  slight 
inflammatory  reaction  is  occasionally  seen  aii<l  if  treated  with  a  cold  solution  of 
formalin,  1  to  2000,  disappears  quickly. 

Membranous  Coxjuxctivitis    (Diphtheritic  Cox.tuxctivitts). 

We  occasionally  see  membranous  patches  on  the  surface  of  the  con- 
junctiva.    This   inem1)ranous  deposit    is  sometiiiKs  distinctly   dipbtboi-itic. 


'Formalin  is  a  4.5  per  cent,  solution  of  foniialdchydc.      Formalddiyde  itself  is  a 
gas  and  a  strong  escharotic. 


864  DISEASES    OF    THE    EYE. 

a  culture  taken  showing  the  jjresence  of  the  Klebs-Loeffler  bacillus.  To 
dift'erentiate  clinically  between  the  diphtheritic  and  non-diphtheritic  type 
is  sometimes  impossible.  1  have  seen  membranous  coujuiu'tivitis  at  the 
Willard  Parker  Hospital  in  which  the  disease  clinically  resembled  diph- 
theria and  still  the  Klebs-Loefflcr  bacillus  was  absent.  In  one  case  seen 
by  me  the  streptococcus  alone  was  present.  The  clinical  history  of  the  case 
is  an  important  guide  in  the  diagnosis.  If  another  case  of  diphtheria  exists 
at  the  same  time  in  the  same  house,  tbe  question  of  transmission  should 
have  weight  in  making  the  diagnosis.  Every  case  of  membranous  conjunc- 
tivitis requires  a  careful  inspection  of  the  fauces.  If  croui)t)us  laryngitis  is 
present,  then  a  greater  probability  of  diphtheria  is  warranted. 

Symptoms. — A  grayish-yellow  patch  can  be  seen  on  the  conjunctiva. 
The  lids  are  very  tender  and  swollen.  They  feel  hard  and  thick  on  palpa- 
tion, and  cannot  be  everted.  Ulceration  or  spbacelati  n  of  the  cornea 
usually  follows.  The  same  systemic  disturbances  nuiy  be  noted  as  are  found 
in  diphtheria  affecting  the  throat.  There  is  usually  fever,  glandular  en- 
largement, loss  of  appetite,  general  prostration,  and  cardiac  disturbances, 
as  has  been  described  in  the  chapter  on  "Diphtheria." 

Prognosis.; — A  very  guarded  prognosis  is  necessary,  as  the  outcome  of 
the  case  de})ends  upon  the  care  bestowed  and  the  time  when  the  case  was 
first  seen.  If  the  disease  has  been  established  a  long  time,  a  greater  de- 
structive tendency  must  be  presumed  than  if  the  case  was  seen  when  it  first 
originated. 

Treatment. — First  isolate.  The  communicable  nature  of  this  disease 
must  be  remembered.  The  family  and  friends  sliould  be  warned  of  the 
danger. 

Local  Treatment. — If  the  eyes  are  thick  and  swollen,  an  ice-bag  or 
ice-cold  pledgets  of  cotton  soaked  in  bichloride,  1  to  2000,  should  be  ap- 
plied. They  should  be  renewed  every  five  to  ten  minutes  night  and  day, 
to  produce  a  good  result.  In  other  cases  warm,  moist  applications  will 
alleviate  pain  and  also  reduce  inflammation. 

Specific  Treaftiient. — Diplitheria  is  diphtheria  whether  it  is  in  the  eye 
or  in  the  throat,  hence  an  injection  of  5000  units  of  antitoxin  should  be 
given  regardless  of  the  age  of  the  child.  The  same  internal  treatment 
which  is  described  in  the  chapter  on  "Diphtheria"  is  recommended  if  we 
desire  successful  results  in  these  cases. 

Granular  Ophthalmia  (Trachoma). 

The  characteristic  feature  lies  in  the  development  on  the  palpebral 
conjunctiva  of  the  so-called  "sago  grains." 

Granular  lids  nnist  be  carefully  considered  owing  to  their  disastrous 
tendency. 


GRAJSlULAll    OJ'IITJIALMIA. 


865 


The  following  table,  slightly  luodilied  Iroiii  iStcpheuson  ('"Epidemic 
Ophthalmia,"  1895)  gives  the  differential  diagnosis  between  folliculosis 
of  the  conjunctiva  and  trachoma : — 


Table  No.   105. 


FALSE  OR  FOLLICULAR  GRANULATION. 
1.  Oval  or  roundish  transparent 
bodies  the  diameter  of  which  never  ex- 
ceeds from  1  millimeter  to  1  Va  milli- 
meters. Of  a  faint  yellowish  hue,  ar- 
ranged in  rows  parallel  to  the  lid  border, 
and  discrete,  ilost  marked  in  inferior 
retrotarsal  fold. 


TRACHOMA. 

1.  Round,  opaque,  ill-defined  bodies,  of 
grayish-white  color  and  extreme  friabil- 
ity. Firmly  and  deeply  embedded  in  the 
conjunctiva,  their  diameter  not  in- 
frequently reaches  2  millimeters  or  more. 
Tendency  to  become  continent  and  form 
masses  or  areas  of  tracliomatous  ma- 
terial. Most  numerous  and  larger  in 
upper  retrotarsal  fold. 


2.  Little  or  no  change  in  the  structure 
of  the  conjimctiva. 


2.  Structural  changes  always  present. 


3.  Papillary  hypertrophy  of  upper  lid  3.  Marked    hypertrophied    papillfe    of 

slight.  upjjer  lid  generally  present. 


4.  Tarsus  never  implicated. 


4.  Tarsus  often  involved. 


5.  Disappear  spontaneously  generally  5.  Spontaneous  cure  may  occur,  but 

and  leave  no  scar.  only    by    cicatrization,    which    may    be 

slight    or    extensive    according    to    the 
amount  of  tissue  involved. 


G.  No  ptosis. 


G.  Ptosis    nearly    always    present    in 
some  degree. 


7.  No  pannus. 


8.  No    trichiasis,    entropion,    or   cica- 
tricial contraction  of  the  cul-de-sac. 

ft.  Most  frequent  in  persons  under  20 
years. 


7.  Keratitis  in  the  form  of  pannus  or 
ulcer  in  about  25  per  cent,  of  the  cases. 

8.  Frequently   leads  to  trichiasis,  en- 
tropion, or  shrinking  of  the  cul-de-sar. 

!).  May  occur  at  any  age. 


10.  Non-contatrious. 


10.  Conditionallv  contagious. 


This  disease  may  frof|uently  assume  an  epidemic  nature.  Dni'- 
ing  the  last  two  years  hundreds  of  cases  have  suddenly  ap])eared  in  our 
city.  The  ease  with  whicii  all  infectious  diseases  spread  in  the  congested 
portions  of  our  city  applies  to  ti-achoma.  For  this  reason  school-children 
and  inmates  of  institutions  and  hospitals  should  liave  the  eyes  carefully 
inspected  on  admission  to  exclude  trachoma,  in  our  coimtry  the  native 
American  Indian  suffers  from  this  disease,  so  do  tlie  Irish,  Polish,  Italians, 


866 


DISEASES    OF    THE    EYE. 


and  the  Teutonic  races.  It  is  tlicrcfore  quite  probable  that  this  disease  is 
spread  more  or  less  among  all  races.  One  race  is  exempt,  namely,  the 
negro. 

Treatment. — Of  all  methods,  expression  is  the  method  generally  used. 
The  morbid  tissue  is  thereby  dislodged  and  removed.  Actual  cauterization, 
galvano-cautery,  or  the  solid  nitrate  of  silver  stick  is  mentioned  by  some, 
but  should  be  used  only  by  those  familiar  with  the  eye.  The  advice  that  I 
give  in  my  office  to  patients  suffering  with  trachoma,  is  to  recommend  thera 
to  an  eye  specialist. 


Fig.  287. — Traclioma,  Sliowing  Round,  Opaque  Bodies  in  Upper  and 
Lower  Lids.  "Sago  grain"  type.  Fioni  a  photograph — frequent  type  seen 
in  cliihlrcn.     (Original.) 


Blepharitis. 

This  disease  is  characterized  by  a  sub-acute  or  chronic  inflammation 
along  the  margin  of  the  lids. 

Two  classes  of  cases  might  be  noted.  Firsl,  those  in  which  slight 
crusts  appear  on  the  edges  which,  when  cleared  off,  show  no  loss  of  sub- 
stance; simply  reddened  margin.  This  would  include  the  cases  of  mar- 
ginal eczema,  so  called.  Second,  those  cases  which,  when  cleared  of  crusts, 
show  ulceration. 

The  first  class  of  cases  seek  treatment  for  cosmetic  results.  There  is 
no  pain,  only  a  slight  discomfort  exists.  These  cases  are  all  aggravated 
by  exposure  to  dust,  wind,  heat,  or  long  spells  of  work. 

The  second  class  of  cases  is  more  serious.  At  first  they  present  a  dusky 
margin  and  gluing  together  of  eyelashes,  due  to  excessive  secretion,  which 


HORDEOLUINI. 


867 


gradually  progresses.  Beneath  the  crusts  ulcers  form.  Excoriations  and 
pustules  about  the  hair  follicles  interfere  with  the  growth,  so  that  the 
lashes  fall  out  or  become  stunted.  The  vascularity  continues,  increasing  the 
thickness  of  the  lids  with  new  connective  tissue.  The  gradual  contraction 
of  this  new  scar  tissue  leads  to  eversion  of  the  lids  with  resulting  epiphora, 
or  overflow  of  tears,  presenting  a  disagreeable,  raw-looking  surface. 

Treatment. — Generally  speaking,  the  treatment  consists  of  removing 
the  crusts  or  scabs  by  any  warm  alkaline  lotion,  such  as  bicarbonate  of  soda, 
or  biborate  of  soda,  10  to  20  grains;  aqua?,  1  ounce.  Massage  of  the  lids 
with  red  or  yellow  oxide  or  white  precipitate,  2  to  8  grains;  vaseline,  1  ounce, 
should  follow. 

A  mild  ointment  should 
be  used — a  strong  one  in- 
creases the  irritation.  All  re- 
fractive errors  must  be  cor- 
rected. Epilation  of  the 
lashes  sometimes  promotes  a 
cure  when  commenced  in  the 
early  stages  of  the  disease. 
The  general  condition  of  the 
patient  must  be  looked  after, 
and  iron,  arsenic,  codliver- 
oil,  or  similar  tonics  and  hy- 
gienic treatment  as  indicated 
should  be  prescribed. 

Hordeolum,  or  Stye. 

This  disease  is  character- 
ized by  an  inflammation  of 
the  connective  tissue  about  a 
hair  follicle  along  the  lid 
margin.  A  hard,  circum- 
scribed, inflammatory  nodule  forms,  which  may  suppurate.  Occasionally,  it 
remains  as  a  hard  lump,  and  still  in  other  cases  the  lid  becomes  swollen  and 
oedematous.  A  close  examination,  however,  will  show  the  inflammatory  spot, 
which  as  soon  as  it  appears  yellowish  should  be  incised  and  the  pus  evacu- 
ated. 

Treatment. — The  general  treatment  consists  in  hot  applications  to 
favor  resolution.  To  prevent  successive  crops,  the  massaging  of  the  lids 
with  an  ointment  of  hydrarg.  ox.  flav.,  V2  to  2  grains ;  vaseline,  2  drachms, 
has  an  excellent  effect.  The  infection  from  the  pus  may  be  prevented  by 
the  use  of  argyrol  in  a  5  per  cent,  solution,  one  drop  two  or  three  times 
daily. 


Fig.  288. — Method  of  Everting  Eyelid. 
(After  Davis  and  Douglass.) 


368  DISEASES    OF    THE    EYE. 

These  successive  styt's  sliow  some  (lisciisc  of  the  lid  iuargiu,  as  bleplia- 
riiis,  some  derangement  of  the  general  system,  or  eye-strain,  especially  iu 
hypermetropia. 

Phlyctenular  Conjunctivitis. 

This  affection  is  one  of  cliildhood  and  is  seen  in  malnutrition  after 
the  acute  exanthemata;   also  in  marasmic  or  scrofulous  children. 

Small  elevated  spots,  papules,  or  pustules  the  size  of  a  mustard  seed 
are  found  in  this  condition.  When  the  e])ithelial  covering  is  shed  they 
become  superficial  ulcers.  They  are  either  single  or  multiple,  and  appear 
as  pinkish,  yellowish,  or  grayish  spots.  There  is  very  often  a  great  dread  of 
light — photophobia — which  leads  to  spasms  of  the  lids — blepharospasm. 
There  are  also  at  times  pain,  burning  sensation,  and  lachrymation. 

Treatment. — Local  treatment  consists  of  bathing  Avilh  a  saturated  solu- 
tion of  boric  acid.  If  any  excoriation  exists  at  outer  canthus,  touching  it 
with  nitrate  of  silver  generally  eft'ects  a  cure. 

If  the  symptoms  show  that  the  condition  is  subacute  or  chronic  then 
stimulating  applications   are   required,   as: — 

IJ  Hydrarg.  ox  flav 4  to  8  grains 

Aaseline   1  ounce 

M.  and  apply  three  times  a  day. 

I  have  had  excellent  results  by  touching  the  affected  j)arts  lightly  with 
a  solid  stick  of  alum  or  copper. 

If  there  is  much  corneal  involvement: — 

IJ  Atropin   sulph '/,  grain 

Aq.   dest 2  drachms 

Sig. :     One  drop  in  the  eye  once  or  twice  daily  may  have  to  be  used. 

For  the  blepharospasm,  a  force  I  opening  of  the  lids,  an  occasional  drop 
of  a  2  per  cent,  solution  of  cocaine,  or  a  sudden  plunging  of  the  head  iu 
cold  water  will  relieve  the  cimdition. 

General  Treatment. — This  consists  in  the  hygienic  care  of  the  child 
and  tonic  treatment.  The  eyes  should  be  kept  clean  and  open,  dark  glasses 
should  be  worn  if  necessary.  No  dark  room,  bandages,  or  eye  shields  should 
be  allowed.  The  bowels  should  be  regulated.  The  diet  should  be  looked 
into.  All  sweets  interdicted,  meat  given  occasionally,  and  milk  foods  or- 
dered. Give  plenty  of  fresh  air.  outdoor  exercise,  and  bathing.  Tonics, 
such   as  codliver-oil,  syr.   ferri    iodide,   str^'chnine,   etc.,   should  be  given. 


CHAPTER  III. 

DISEASES  OF  THE  SKIN. 

Eczema. 

This  eruptive  disease  is  very  frequently  seen  in  infants  as  well  as  in 
older  children. 

Etiology. — Irritation,  be  it  an  irritant  soap  or  an  irritant  discharge, 
can  give  rise  to  eczema.  Eczema  is  frequently  an  external  manifestation 
of  toxic  conditions.  The  frequency  with  which  eczema  is  seen  in  children 
with  dyspeptic  conditions  certainly  invites  consideration.  C^hildren  having 
rickets  are  frequent  sufferers  with  eczema.  Some  authors  believe  that 
pathogenic  bacteria  can  enter  the  skin  and  set  up  eczema.  While  this  ap- 
pears plausible,  it  remains  to  be  proven.  It  is  found  associated  with  de- 
ficient elimination  from  the  skin  in  the  unclean,  in  d_yspeptic  conditions 
when  the  stonuich  and  bowels  arc  not  properly  functionating,  and  also 
when  the  kidneys  do  not  properly  act.  I  have  frequently  seen  children 
with  a  facial  eczema  which  appeared  when  oatmeal  was  given  and  disap- 
peared when  the  same  was  stopped.  Eczema  uuiy  l)e  due  to  reflex  irrita-. 
tion.  Holt  says  that  cases  which  accompany  dentition  and  those  due  to 
genital  irritation  can  be  called  reflex. 

This  disease  can  be  either  localized  (refjional),  as  when  it  is  confined 
to  the  face  or  lietween  the  thighs,  or  it  can  be  general  or  unirerml. 

Symptoms. — There  is  always  an  intense  itching  or  burning  with  the 
appearance  of  the  eczema.  On  tlie  cheeks  it  usually  begins  with  ''small 
red  papules,  later  these  coalesce  and  there  is  a  moist  red  surface  exuding 
serum  or  sero-pus."  Children  scratch  and  thus  usually  jiroduce  bloody 
streaks,  ''j'he  crusts  have  a  ycllowish-l)rn\vn  ;i]>|H^arance.  There  is  a  red- 
ness, thickening,  and  always  scaliness  of  the  skin.  The  glands  in  the  im- 
mediate neigh])orhood  are  usiiallv  swollen  :    the\-  rarely  lead  to  suppuration. 

Eczema  fre(nienfly  spreads  fi-om  the  face  to  the  forehead  and  the  neck. 
and  I  have  seen  it  involxc  the  whole  bend. 

liii'ant  O.  S.,  seven  month-!  old,  was  nursed  about  six  weeks  at  his  mother's 
breast.  He  Avas  then  fed  on  top  milk  and  bailey  water.  As  this  disaj^reed  he  was 
given  barley  water.  He  then  had  dyspeptic,  greenish  stools,  and  the  feeding  was 
chanp:ed  to  milk  and  riee  water,  which  seemed  to  acree  quite  well.  He  friii'K'd  steadily 
one-half  pound  every  week  for  Ihe  next  three  months.  He  was  at  the  seashore  all 
summer  and  had  no  evidence  of  sinnmcr  complaint.  When  seven  months  old  he 
was  slijjhtly  constipated  and  wifli  it  lind  dyspeptic  fermenlaf ion.  His  appetite  was 
poor.      It  was   necessary  to  stimulate   the  bowels  to  produce   projicr  evacuations, 

(st;i.) 


870  DISEASES    OF    THE    SKIN. 

Teething  appeared  at  about  the  eighth  month.  At  the  same  time  the  child  had  a 
severe  attack  of  influenza  of  the  gastric  type,  with  high  fever,  anorexia,  and  gastro- 
intestinal atony.  At  this  time  a  scaly  and  papular  eczema  appeared  on  one  cheek 
and  rapidlj-  spread  to  both  cheeks.  With  the  application  of  a  bland  ointment  con- 
sisting of  zinc  oxide  and  vaseline  it  disappeared.  One  week  later  I  again  saw  tliis 
child  with  a  relapse  of  high  fever  and  dyspeptic  symptoms,  and  a  severe  eczema 
covering  an  area  larger  than  before.  It  was  veiy  red  and  angry  looking  and  weep- 
ing in  character.  A  gauze  mask  saturated  with  calamine  and  zinc  lotion  (3  per  cent.) 
produced  a  marked  improvement,  besides  relieving  the  itching.  Internally  I  gave  rhu- 
barb and  soda  tablets  in  addition  to  cutting  down  the  quantitj'  of  milk  one-half 
of  the  previous  strengih.  After  three  weeks  of  this  form  of  treatment  I  was  able  to 
rctiu-n  to  the  former  full  milk  feeding  and  the  eczema  did  not  return. 

The  following  prescriptions  are  valuable: — 

CALAMINE    LOTIOX. 

li  Pulv.  calamini 2  parts 

Pulv.  zinci  ox 2  parts 

Gh'ccrini   1  part 

Aq.  rosae 30  parts 

unna's  soft  zinx'  paste. 
B  01.  lini, 
Aq.  calcis, 
Zinci  ox., 
Cretfe of  eaeh,  equal  parts 

Treatment.— Bland  imirritating  applications,  such  as  rice  powder, 
zinc  o.xide,  stearate  of  zinc,  talcum,  or  cornstarch,  are  very  cooling,  and 
seem  to  act  by  absorbing  the  heat  and  moisture  if  any  be  present. 

Bathing  in  Eczema. — I  have  frequently  found  an  apparently  cured  case 
of  eczema  break  out  anew  with  a  red  blush  and  eczematous  patches  after 
one  ordinary  cleansing  bath  was  given.  In  the  acute  stages  water  sliouhl 
he  omitted.  Applications  of  a  o  or  10  per  cent,  calamine  and  zinc  salve 
or  lotion,  as  described  in  the  clinical  case  above  given,  are  very  beneficial. 
Soap  should  never  be  used.  "When  hard  crusts  cover  the  surface  of  the 
skin  and  cannot  be  softened  1)y  the  ordinary  applicat'on  of  salves,  the  fol- 
lowing treatment  should  be  instituted :  A  bland  bath  consisting  of  one 
pound  of  oatmeal  in  a  cheese-cloth  bag,  should  be  thoroughly  soaked  in  hot 
water  for  at  least  one-half  hour,  and  enough  water  added  to  bathe  the 
eczematous  parts.  After  thorough  soaking  in  this  oatmeal  bath  the  cala- 
mine and  zinc  or  a  2  per  cent,  boric  acid  and  vas'^'line  ointment  should 
be  applied.  One  hath  only  sliouhl  hr  r/irri}.  The  salve  should  be  applied 
three  times  a  day  for  at  least  one  week.  Irritating  ointments,  or  those 
containing  tar,  should  be  avoided  in  the  acute  condition. 

EczinrA  I?rp.nr:\r. 
The  eczematous  blush  aflPecting  the  face  may  be  mistaken  for  erysip- 
elas.    Erysipelas  usually  occupies  a  smaller  area,  generally  on  the  bridge  of 


URTICARIA. 


871 


the  nose.  High  fever  usually  aeeoui]jauies  erysipelas;  this  will  easily  dif- 
i'ereutiate  the  condition.  The  treatment  is  the  same  as  that  outlined  in 
the  article  on  ''Eczema." 

SALICYLIC-SULPHUR  PASTE. 

IJ  Ac.  salicyl 1  part 

Sulph.   depur 5  parts 

Petrolatum  25  parts 

Zinei  oxid 10  parts 

Amylum     10  parts 

ICHTHYOL    OIXTMENT. 

Amnion.    8ulph-iclith y(jlat 5  parts 

Ap.  dest 5  parts 

Adeps  benzoat 15  parts 

Adeps   lanae    25  parts 

Eczema  Ixtektkigo. 

In  fat  children  where  two  opposing  surfaces  of  skin  are  in  contact, 
such  as  hetweeu  the  thighs  or  toes  or  in  the  armpits,  a  red  form  of  inflam- 
mation frequently  ensues.  It  is  sometimes  accompanied  by  a  thin,  foul- 
smelling  discharge,  which  may  Ije  serous,  but  very  rarely  is  purulent.  This 
condition  is  more  apt  to  be  noticed  in  the  unclean. 

Treatment.  —  Eemove  the  cause  by  separating  the  parts.  Sprinkle 
freely  with  talcum,  zinc  oxide,  lycopodium.  Fuller's  earth,  or  any  good 
infant's  powder.  In  severe  cases  separate  the  parts  by  placing  a  sterile  pad 
of  cheese-cloth  on  both  skies  of  which  zinc  salve  is  smeared.  All  warm 
clothing  should  be  avoided.  When  severe  excoriation  results  from  dis- 
charges and  is  not  checked  by  the  application  of  bland  salves,  then  cool 
lead  and  opium  wash  applied  for  a  day  or  more  is  soothing  and  will  reduce 
the  inflammation. 

Erythema. 
Local  irritation  such  as  might  be  caused  by  a  mustard  plaster  or  the 
friction  of  a  dress,  producing  a  "chafe,"  or  irritating  secretions,  such  as 
a  purulent  ophthalmia  or  acrid  discharge  from  the  nose,  produces  this  ery- 
thema. It  is  frequently  seen  in  infants  on  the  buttocks  from  lack  of  clean- 
liness. When  seen  on  the  buttocks  it  may  be  mistaken  for  syphilis.  Ery- 
tliema  is  easily  diflTcroiiliatcd  from  sy])hib's  by  the  absence  of  snuffling  of 
the  nose,  of  the  liam-colorod  cniption.  and  of  the  inelastic  cracked  appear- 
ance of  the  solor;  and  pnlms. 

TTRTirAETA  (TTtves:    Xettle  T?artt). 

This  inflammatory  condition  of  the  skin  appears  very  suddenly.  No 
special  portion  of  th(^  l)ody  is  exempt :    thus,  it  may  occur  on  the  face, 


872  DISEASES    OF    THE    SKIN. 

abdomen,  or  extremities.  It  consists  of  irregular  sliaped  blotches  called 
ivheals.  When  these  spots  disappear  they  leave  no  trace  behind.  There 
are  several  varieties  of  urticaria. 

Urticaria  annularis  occurs  in  rings. 

Urticaria  fiyurata  occurs  in  spirals. 

Urticaria  vesiculosa   has  vesicles  on   the  suinniit  of   the  wheal. 

Urticaria  bullosa  is  a  bullous  development  on  summit  of  wheal. 

Urticaria  papulosa  is  a  wheal  coml)ined  with  a  papule. 

Urticaria  tuberosa  are  giant  wheals. 

Urticaria  lianiorrliagica   is  a  combination  of  urticaria  with  purpura. 

Urticaria  pigmentosa   is   a   pigmentation   following  the   wheals. 

The  form  most  frequently  met  with  in  children  is  likely  due  to  (a) 
ptomaine  poisoning;   (b)  the  result  of  some  toxin  in  the  system. 

Causes. — Shell-fish,  strawberries,  and  frequently  cereals  seem  to  be  the 
cause  of  urticaria  in  some  children.  There  is  usually  some  gastric  or  gastro- 
intestinal disturbance  at  the  time  of  the  appearance  of  this  rash.  There 
seems  to  be  a  ])eculiar  idiosyncrasy  in  some  children  to  quinine  and  to 
other  drugs  whicli  will  bi'ing  out  an  attn.ck  of  urticaria.  A  great  many 
children  have  severe  urticaria  after  an  injection  of  antitoxin.  (Read 
article  on  "Antitoxin  Rashes.'')  Insect  hites  will  sometimes  cause  this 
condition. 

Symptoms. — There  is  severe  itching,  and  scratching  will  frequently 
develop  a  new  rash.  Fever  sometimes  accompanies  this  condition.  Urti- 
caria once  seen  is  very  easily  recognized  and  is  not  hard  to  differentiate. 

The  prognosis  is  usually  good.  We  must  rcmem1)er  that  children  prone 
to  idiosyncrasies  will  have  urticaria  quite  frequently,  thus  it  will  depend 
on  the  diet  as  to  whether  or  no  the  rash  remains  away. 

Treatment. — The  first  thing  to  do  is  to  cleanse  the  gastro-intestinal 
tract.  A  saline  or  citrate  of  magnesia  will  always  do  good.  Next  in  im- 
portance is  the  regulation  of  the  diet.  If  a  cause  is  found,  remove  the 
h^ame. 

Locally. — The  severe  itching  can  best  be  allayed  by  making  a  paste 
of  bicarbonate  of  soda  and  cold  water.  Rub  this  paste  into  the  hives.  A 
cool  tub  bath,  containing  several  ounces  of  bicarbonate  of  soda,  will  fre- 
quently relieve  the  itching,  ^rontliol.  o  io  10  grains  to  1  ounce  of  water, 
applied  by  means  of  a  camers-hair  Inrush,  is  advised  by  some.  Evaporat- 
ing lotions,  such  as  lead  and  opium  wash  or  a  weak  solution  of  vinegar  and 
water,  or  carbolated  water,  are  recommended  externally. 

Large  quantities  of  water  should  l)e  given  for  thirst.  It  will  also  aid 
in  eliminating  toxins  through  the  kidneys. 


PSORIASIS.  373 

Herpes  Zoster  (Shingles). 

"This  is  an  acute  inflammation  consisting  of  a  group  of  vesicles.  It  is 
mostly  seen  over  a  surface  of  skin  corresponding  to  a  definite  nerve  tract. 
It  is  accompanied,  by  neuralgic  pain." 

Symptoms. — As  a  rule  there  is  a  broad  band  of  vesicles  corresponding 
to  the  affected  area,  usually  following  a  nerve  tract  along  the  limbs  or  along 
the  borders  of  the  ribs.  It  develops  very  rapidly  and  frequently  resembles 
an  erythema.  The  crop  of  vesicles  is  frequently  so  thick  that  they  almost 
touch  one  another. 

Prognosis. — As  this  is  a  self-limited  disease  the  jn-ognosis  is  good, 
although  neuralgic  pains  may  persist  for  some  time  after  the  disappearance 
of  the  eruption. 

Treatment. — Avoid  irritant  salves  and  use  cooling  dusting  powders, 
such  as  bismuth,  cornstarch,  wheat  flour,  or  powdered  zinc  oxide.  The 
affected  part  should  be  covered  with  linen  or  gauze,  not  flannel  or  wool.  To 
allay  intense  itching  or  inflammation  use  calamine  and  zinc  lotion  (see 
chapter  on  "Eczema"). 

Chloasma  (Tinea  Versicolor:    Liver  Spots). 

This  is  a  very  mild  form  of  eruption  in  which  brown  patches  of  skin 
are  seen.     It  is  caused  by  the  invasion  of  a  fungus. 

Treatment. — The  application  of  Avhite  precipitate  ointment  or  1  per 
cent,  bichloride  in  alcohol  has  served  me  very  well  in  removing  the  same. 

Psoriasis. 

This  is  a  chronic  inflammatory  disease  affecting  the  extensor  sur- 
faces.   It  consists  of  a  red  scaly  patch  in  which  white  silvery  scales  abound. 

Etiology. — There  is  no  specific  factor,  as  it  is  found  in  both  tlie  rich 
and  poor,  although  it  frequently  follows  malnutrition  of  the  body  such 
as  we  see  after  the  acute  infectious  diseases.  This  condition  also  fre- 
quently affects  children  of  gouty  parentage. 

Symptoms. — The  extensor  surfaces  are  \isually  affected,  hence  the  dis- 
ease will  be  found  on  the  extensor  sides  of  the  arms  and  legs.  'J'he  sym- 
metrical arrangement  of  this  eruption  on  both  sides  of  the  body  is  a  char- 
acteristic condition. 

Prognosis. — This  should  always  ])e  cautiously  given.  As  the  disease 
has  a  chronic  tendency  it  may  remain  for  years  unless  actively  treated. 

Treatment. — Locally  : — 

R  Kesorcin    1  ^'^■!^'n 

Vaseline    1  ounce 


374  DISEASES    OF    THE    SKIN. 

Great  care  should  be  used  in  prescribing  pure  alcoliol  or  tar.  Such 
strong  remedies  should  be  avoided  and  a  dermatologist  should  be  consulted 
bel'ore  advising  heroic  treatment.  The  following  ointment  has  acted  very 
well  in  these  conditions: — 

B  Ac'idi  carboliei 5  giains 

Bisni.  subiiitr V2  diiichiii 

Unguent,  hydraiy.  aiiunon 1-  drachms 

Ung.  aquoe  rosse ad     1  ounce 

M.  To  be  thoroughly  rubbed  into  the  atrected  patches,  either  alone  or  after 
washing  with: — 

I^  Acidi  salicylici    1  scruple  t;)  1  drachm 

Spts.  vini  reetif 1  ounce 

Glycerini    : 4  drachms 

Aqute  rosa? ad  4  ounces 

(Bulkley) 

Systemic  Treatment. — No  one  must  expect  to  cure  this  disease  unless 
the  emunctories  are  properly  looked  after.  We  must  keep  the  bowels  loose, 
the  kidneys  active,  and  give  a  vegetable,  fruit,  and  cereal  diet.  The  dairy 
products  shouUl  be  permitted,  but  meat  must  be  excluded. 

Eestorative  treatment  such  as  codliver-oil,  iron,  and  arsenic  should  be 
given  liberally.  In  this  disease  arsenic  proves  itself  of  great  value.  Ar- 
senic need  not  Ije  feared  and  can  be  given  to  children  in  very  large  doses. 
Fowler's  solution,  in  3  to  10-drop  doses  three  times  a  day,  is  usually  suffi- 
cient. 

Impetigo. 

This  infectious  and  contagious  disease  is  characterized  by  an  eruption 
which  may  appear  on  any  part  of  tlie  body.  It  is  most  frequently  seen  on 
the  exposed  parts,  usually  on  the  face  and  hands.  It  is  most  probably 
caused  l)y  the  presence  of  the  staphylococcus  or  streptococcus. 

Symptoms. — There  may  or  may  not  be  fever  at  the  onset  of  the  erup- 
tion. The  eruption  usually  commences  on  the  face  and  hands.  It  is  easilv 
communicated  from  the  sick  to  the  well,  as  the  following  case  Avill  illus- 
trate : — 

F.  R.,  2  years  old,  was  sent  to  me  by  Dr.  W.  H.  The  child  had  been  in 
good  health  when  one  day  the  mother  noticed  a  pustular  eruption  on  the  face, 
chiefly  on  the  cheeks.  loiter  it  spread  to  the  scalp  and  hands.  It  was  associated 
with  scabies  and  contracted  by  scratching.  The  infection  spread  to  a  second  child 
and  I  was  informed  that  some  children  playing  with  the  patient  contracted  tha 
disease.     The  treatment  consisted  in  clijjping  llie  hair  and  saturating  the  parts  with 

B   Tchl  hyol    1   drachm 

\'as(dine    1  ounce 

This  was  a))|)li<'d  Ihree  limes  a  day  with  good  result.  Attention  was  directed  to  the 
condition  of  the  stomach  and  bowels.  Mist,  rhei  et  sodiie,  a  tea  spoonful  was  given 
three  times  a  day. 


MILIARIA    PAPULOSA.  375 

The  disease  can  easily  be  carried  by  clothing  infected  with  the  dis- 
charges from  the  crusts.  In  one  case  1  recall,  the  child  contracted  im- 
jjetigo  by  wearing  the  stockings  of  her  older  sister  who  was  sick  with  the 
disease. 

Treatment. — A  general  outline  of  the  treatment  has  already  been 
described  in  the  clinical  case  given  above. 

A  tub-bath  consisting  of  kali  sulphur  (one  ounce),  dissolved  in  a 
porcelain  or  wooden  tub  full  of  water.  The  temperature  of  this  bath  should 
be  about  100°  F.,  and  the  duration  of  the  bath  about  fifteen  minutes.  This 
bath  should  be  repeated  every  night,  before  retiring,  for  one  week.  Follow 
the  same  with  the  ichthyol  ointuient  well  rubbed  in,  as  above  described. 

Pediculosis. 

Among  the  poor  or  unclean  we  frecjuently  see  this  condition.  It  is 
caused  by  the  invasion  of  a  parasite,  the  pediculus  capitis.  There  is  usually 
an  eczematous  condition  and  the  adjacent  glands  are  swollen.  The  habitat 
of  the  pediculus  is  in  the  hair,  but  it  causes  eczematous  patches  by  irrita- 
tion. 

Treatment. — First  remove  the  hair  if  it  is  at  all  possible;  if  not, 
saturate  the  hair  with  petroleum.  This  should  be  left  on  about  five  or  six 
hours,  after  which  the  scalp  and  hair  should  be  drenched  with  warm  soapy 
water.  The  same  treatment  will  be  necessary  every  few  days  until  a  cure 
is  effected. 

Tincture  of  larkspur  (tr.  delphiu.)  is  another  valuable  preparation 
when  petroleum  is  objectionable.  The  hair  and  scalp  should  be  thoroughly 
saturated  with  larkspur  morning  and  evening  and  then  thoroughly  washed. 

Miliaria  Papilosa  (Liciiex  Tropicus:    Prickly  Heat). 

This  variety  of  skin  disease  is  frequently  seen  in  summer.  It  consists 
of  bright  red  papules  on  the  summits  of  which  there  are  very  tiny  vesicles, 
at  times  pustules  may  also  be  seen.  The  eruption  is  usually  coufined  to 
those  parts  which  are  warmly  clad,  so  that  tlio  abdomen,  chest,  and  the 
extremities  are  most  frequently  covered.  Eczema  frequently  follows  this 
condition,  and  if  severe  scratching  takes  place,  local  infection  ending  in 
furunculosis  may  occur.  The  other  parts  of  the  body  which  do  not  have 
the  eruption  usually  show  extensive  perspiration.  This  eruption  comes 
and  goes  very  fiuickly.  It  is  fre(|uently  mistaken  for  scarlet  fever.  'I'lic 
absence  of  fever,  lite  ii])])<'nrniicc  of  ibc  tongue  ami  ibront.  and  tlie  absence 
of  tb(>  prodromnl  svmptonis  will  easily  dilTci-cutiate  iliis  condition. 

Treatment. — Phu1)arl)  and  soda  or  a  dose  of  calomel  at  tbe  beginning. 
If  the  kidneys  are  inactive,  tbcn  10  to  ■»()  drops  of  sweet  spirits  of  niter 
should  be  given,  and  repeated  two  or  tliree  times  a  day.     For  tlie  intense 


876  DISEASES    OF    THE    SKIN. 

itc-liing  the  application  of  a  paste  consisting  oi'  bicarbonate  of  soda  and 
water,  will  stop  the  itching.  The  body  should  be  made  comfortable  b}- 
removing  all  warm  clotliing.  A  tepid  alkaline  bath,  temperature  70°  F. — 
a  bath  to  wliich  several  ounces  of  bicarbonate  of  soda  has  been  added — 
is  very  grateful  and  will  give  (puck  relief.  After  the  bath  dry  the  bodv 
thoroughly  and  dust  cornstarch  or  wheat  flour  with  talcum  or  zinc  oxide, 
and  let  the  child  sleep  with  as  little  clothing  on  as  possible.  If  im- 
provement does  not  follow  within  twenty-four  hours,  then  the  applicat'on 
of  the  following  salve  will  relieve  itching  and  reduce  the  inllammation : — 

IJ  Zinc  oxide 1  drachm 

Calamine   1  drachm 

Cold  cream   1  ounce 

M.     Apply  three  times  a  day. 

Miliaria  1\L"i?ua  (Stkoi'iiulus  Infantum:    Ked  Gum). 

This  rash  is  tbe  result  of  an  irritation  due  to  perspiration.  It  con- 
consists  of  red  ])apuk's,  sometimes  having  tiny  vesicles.  It  is  usually  seen 
on  the  cheeks  of  an  infant  and  always  upon  the  side  on  which  the  infant 
sleeps. 

The  treatment  is  the  same  as  that  given  in  the  chapter  on  "Miliaria 
rai)ulosa." 

Suuamina. 

Sudaiiuna  are  small  ])early  bodies  occurring  dui'ing  fever  or  exhausting 
diseases.  They  are  usually  seen  over  the  sweat  ducts.  They  are  easily 
absorbed  and  fresh  crops  take  the  place  of  these  tiny  vesicles. 

Lentioo  (Freckles). 

This  is  a  very  common  affection  of  the  skin.  It  is  usually  seen  in 
children  over  5  years  of  age,  and  most  especially  in  those  having  blonde 
or  red  hair.  The  skin  is  certainly  more  sensitive  to  sunlight  in  such  cases, 
and  successive  crops  of  freckles  frequently  appear  after  exposure  to  the 
light. 

The  treatment  consists  in  protecting  the  skin  against  exposure  to  the 
light.  The  freckles  can  be  removed  by  a  mild  form  of  counter-irritation 
such  as  the  application  of  a  1  per  cent,  solution  of  bichloride  of  mercury. 
Apply  on  cotton  to  the  affected  area  for  three  or  four  successive  hours.  This 
form  of  counter-irritation  destroys  the  skin,  causing  it  to  desquamate.  The 
new  ej)idermis  which  appears  is  free  from  this  jiigment. 

SlOHOKlilin^A. 

Tliis  is  a  very  common  condition  of  thick,  dry.  crusty  formation  whicli 
occurs  on  the  head  of  infants.     It  most  frequently   involves   that  region 


FLllLXCLE.  S77 

surroniiding  tlie  anterior  fontanel.  There  are  two  varieties:  (a)  sebor- 
rhoea  oleosa;  {b)  seborrhijea  sicca.  Some  authors  state  that  if  the  vernix 
caseosa  in  the  new-])orn  is  allowed  to  continue  it  passes  into  a  seborrhoea 
and  may  eventually  become  an  eczema.  When  carefully  examined,  sebor- 
rhoea  will  be  foimd  to  consist  of  epithelial  cells,  fat,  and  chiefly  dirt.  There 
are  no  inflammatory  symptoms.  When  the  scales  are  removed  the  skin  is 
usually  found  normal. 

Treatment. — The  following  is  recommended  : — 

IJ  Salicylic   acid 1.5  grains 

Vaseline    1  ounce 

M.  Rub  the  scalp  thoroughly  several  times  a  day  and  leave  on  over  night. 
Wash  scalp  with  soap  and  warm  water  the  following  morning.  If  necessary  repeat 
several  evenings  and  wash  in  the  morning  a.s  above  directetl.  Sulphur  soap  is  useful 
in  this  condition.  The  officinal  ointment  of  sulphur  can  be  rubbed  into  the  scalp  if 
this  condition  recurs. 

Furuncle  (Boil). 

This  inflammatory  condition  occurs  around  a  hair  follicle  or  a  gland 
of  the  skin.  It  is  most  likely  caused  by  scratching,  during  which  process 
there  is  an  infection  of  the  follicle  with  pyogenic  bacteria  such  as  staphy- 
lococcus pyogenes  aureus.  Frequently  we  see  boils  scattered  through  the 
scalp  in  large  crops.  At  other  times  they  occur  singly.  A  boil  begins 
as  a  small  red  spot  in  the  true  skin,  very  tender,  and  growing  larger  and 
larger.  On  palpation  the  center  is  soft  and  there  is  a  tendency  to  sup- 
puration. After  suppuration  has  taken  place  and  the  boil  emptied  the 
swelling  subs  dcs. 

Differential  Diagnosis. — A  furuncle  has  but  one  point  of  suppuration, 
whereas  the  carliuncle  has  many.  A  furuncle  is  usually  a  small  swelling. 
A  carbuncle  very  large,  frequently  several  inches  in  diameter. 

Diagnosis. — The  diagnosis  is  usually  very  simple.  This  condition  is 
usually  met  with  in  rickets.  It  especially  affects  those  children  having  a 
tendency  to  liead  sweating. 

The  prognosis  is  usually  very  good. 

Treatment. — Aseptic  surgical  details  are  demanded  in  each  and  every 
instance.  The  seal})  should  be  shaved.  The  area  of  the  skin  involving  the 
furuncle  should  be  w^ashed  with  carbolated  soap  and  water,  and  subse- 
i|uently  with  water.  A  free  incision  should  be  made,  the  pus  liberated,  and 
the  part  dressed  with  sterile  gauze. 

Iron,  codliver-oil.  and  f)ther  restoratives  are  indicated.  The  value  of 
nutritious  food  must  not  be  overlooked. 


878  DISEASES    OF    THE    SKIN, 

CllUOMC  rEMl'IIKiUS,^ 

This  I'requeutly  lollows  lliu  aeiile  (.oiulitioii.  It  ruscmblcs  the  acute 
disease  in  prochiciiig  a  siiccessiou  of  crops  of  bullie. 

The  prognosis  tlcpeiuls  on  the  condition  of  the  chikl  at  the  time  when 
it  was  first  attacked,  if  tlie  infant  is  underfed  and  its  vitality  lowered 
thereby,  then  active  restorative  treatment  shoidd  l)e  instituted  or  the  cas>^ 
will  be  lost. 

Treatment. — The  l)lc'bs  sliould  not  l)e  ruptured.  They  should  be  al- 
lowed to  dry.  The  surface  of  the  skin  in  the  immediate  neighborhood 
should  be  protected  by  a  bland  non-irritating  ointment  such  as  zinc  salve 
or  diachylon  salve. 

Sprinkling  powder  of  zinc  oxide,  borated  talcum,  or  cornstarch  should 
be  used.  If  the  bulla?  rupture,  the  serum  should  be  absorbed  with  a  little 
cotton  and  the  neighboring  parts  protected  from  the  excoriating  effect  of 
the  contents  of  the  ruptured  bulk^.  Careful  attention  must  be  given  to 
the  stomach  and  bowels.  If  necessary,  a  mild  laxative  should  be  given. 
The  diet  should  be  regulated  both  as  to  quantity  and  quality. 

IST^vus. 

There  are  two  kinds  of  nievus  usually  seen:  (o)  pigmentarA',  (6)  vas- 
cular. Pigmentary  occurs  as  small,  rounded  stains,  whicli  are  either  yel- 
lowish or  dark  brown.  The  cutis  is  raised,  thickened,  and  frequently  sur- 
rounded with  a  tuft  of  hair.  They  are  most  commonly  seen  on  the  face, 
neck,  and  hands. 

Vascular  na>vus  may  be  level  with  the  skin  or  appear  as  tumors  which 
project  beyond  it.  The  former  is  due  to  an  excessive  development  of  the 
capillaries  of  the  skin.  Commonly  met  with  it  is  of  a  purplish  hue, 
although  it  may  be  brick  red,  claret  red,  or  a  livid  blue  color.  They  are 
most  commonly  seen  on  the  face  and  neck. 

Treatment. — Blistering  or  caustics  are  recommended  for  the  cure  of 
this  condition.  I  have  frequently  seen  nuirkcd  benefit  from  linear  scari- 
fication by  the  Paquelin  cautery.  A  radical  operation  should  be  considered 
if  this  milder  form  of  treatment  is  unsuccessful. 

Tinea  Tonsurans  (Ringavorm). 

This  disease  is  caused  by  the  trichophyton  tonsurans.  When  located 
on  the  scalp  it  is  called  herpes  tonsurans;  when  on  other  parts  of  the 
body  it  is  knoM-n  as  herpes  circinatus. 

Microscopical  Appearance. — Squire  says:  "Under  the  microscope  the 
stump  of  the  hair  appears  ragged  on  either  of  its  ends.     Instead  of  break- 


^  See  article  on  "Pemphigus  Neonatorum." 


TI^EA  -TONSURANS.  379 

ing  with  a  clean  fracture,  like  healthy  hair,  the  broken  ends  are  digitated. 
The  structure  ol'  the  hair  is  greatly  altered;  its  libers  are  separated  longi- 
tudinally, and  the  intervals  tilled  with  the  spores  of  the  trichophyton.  On 
the  surface  of  the  hair  are  clusters  of  the  same  spores.  The  magnified 
piece  of  hair  looks  something  like  a  bundle  of  faggots,  with  a  number  of 
berries  sticking  in  clusters  to  its  sides  and  ends,  and  stuffed  here  and  there 
into  its  interstices.  The  spores  of  the  trichophyton  are  rounded,  have  a 
well-defined  outline,  and  measure  about  V5000  i^^ch  across.  In  the  earlier 
stages  of  the  disease,  when  the  hair  has  not  yet  become  so  brittle  as  to 
make  it  impossible  to  extract  the  root,  it  can  be  ascertained  that  the  knob 
of  the  hair,  as  well  as  its  root-sheath,  is  invaded  by  the  spores  of  the  tri- 
chophyton." 

The  disease  commences  with  more  or  less  itching  and  redness  of  some 
parts  of  the  scalp;  sometimes  there  is  swelling.  The  hair  growing  on  these 
patches  loses  its  polish,  and  becomes  dull.  It  is  also  brittle  and  easily  breaks 
off  near  the  root.  This  breaking  off"  of  the  affected  hairs  gives  the  patch 
the  appearance  of  having  been  lately  shaved.  There  is  a  furfuraceous  des- 
quamation plainly  seen  on  the  scalp.  The  hair  follicles  become  erect  and 
the  patch  assumes  a  goose  skin  appearance.  The  margin  of  the  patch  is 
abruptly  defined.  There  are  usually  several  patches  seen  on  different  por- 
tions of  the  scalp.  If  we  attempt  to  pull  out  the  hair  stumps  by  means  of 
a  tweezer  we  will  note  that  only  a  portion  of  it  comes  away,  leaving  the  hair 
root  in  the  skin. 

Treatment. — This  consists  in  first  cutting  the  hair  as  short  as  possible. 
Xear  the  patch  and  around  it  a  strong  antiseptic  soap  such  as  a  l)ichloride 
soap  should  be  used.  Absolute  isolation  should  be  enforced  and  children 
affected  with  the  disease  should  wear  oil-silk  caps. 

In  an  epidemic  of  ringworm  in  the  Xew  York  Infant  Asylum,  tbo 
following  combination  of  l)ichloride  and  kerosene  proved  extremely  satis- 
factory: 10  grains  of  the  bichloride  were  dissolved  in  alcohol,  and  to  this 
were  added  2  ^ / .,  ounces  each  of  olive-oil  and  kerosene.  This  was  applied 
every  day,  being  thoroughly  rubbed  into  the  diseased  patches,  and  the 
whole  scalp  saturated  with  it.  Considerable  irritation  usually  resulted, 
and  every  few  days  the  parasiticide  was  omitted  and  some  simple  emol- 
lient applied  until  tlic  irritation  had  in  a  measure  subsided.  In  some  of 
the  cases,  the  tincture  of  iodine  was  alternated  witli  the  bichloride  and 
kerosene.  Twenty-six  cases  were  treated  after  this  plan  and  all  cured, 
the  average  duration  of  tiic  treatment  being  eiglit  and  a  half  weeks. ^ 

My  own  experience  has  been  very  successful  with  this  method.  Some 
authors  advise  an  ointment  composed  of  precipitated  suljihur  or  citrine  oint- 
ment.    Another  remedv  advocated    in  Ibis  condition   is  washing  the  head 


"•See  C.  (J.  Kcrk-y's  report  in  New  York  .Medical  Journal,  OcIoImt  10.  1S91. 


880  DISEASES    OF    THE    SKIN. 

daily  with  a  strong  antiseptic  soap  and  tlien  apj)l\ing-  nitric  oxide  of  mer- 
cury ointment. 

The  following  method  is  also  of  value: — 

Kemove  the  superficial  scales  with  the  tincture  of  green  soap,  or  by 
the  use,  for  a  day  or  two,  of  the  pure  green  soap  spread  upon  a  piece  of 
lint.  Corrosive  sublimate  in  1  per  cent,  solution  may  be  applied  once  a 
day,  or  the  tincture  of  iodine,  or  carbolic  acid  in  glycerine,  1  to  16,  or  thi- 
white  precipitate  ointment  may  be  employed.  I  prefer  the  chrysarobin 
collodion  painted  over  the  patch  every  day  or  every  other  day.  Kaposi's 
naphthol  ointment  is  recommended  by  Lassar.  Tar  or  sulphur  ointments 
or  Lassar's  paste  may  be  employed  in  obstinate  cases. 

Morris's  thymol-chloroform  oil  is  also  beneficial. 

MOUIUS'S  TUYMOL-CHhOROFORM    OIL. 

3  Thymol 1  part 

Chloroform   4  parts 

01.   olivae 12  parts 

Or:— 

RT'BMMATE    SPIRIT. 

IJ   Hydrarg.  chlor.  corr 1  part 

Spts.  vini  reet i)0()  parts 

Or:— 

TANNIN-SULPHUR  PASTE. 

R  Acid,  tannic 5  parts 

Lac.  sulph 10  part.s 

Pctrolati    50  parts 

Zinci  oxidi   17.5  parts 

Amyli 17.5  parts 

Or:— 

niRYRARORIN  COLLODION. 

IJ  Clirysarobini    1  part 

Collodion  flexible   10  parts 

Verruca  (Warts). 

These  small  tumors  of  the  skin  are  frequently  met  with  in  children. 
They  may  resemble  a  bunch  of  carrots  (verruca  digitata)  or  they  may 
resemble  a  cauliflower.  In  size  they  vary  from  one-sixteenth  to  one- 
eighth  of  an  inch  in  height.  They  frequently  are  seen  on  the  face,  neck,  and 
hands.     Tliey  produce  no  discomfort  and  are  not  serious. 

Treatment. — Freeze  the  parts  with  ethyl  chloride  or  etlier.  Pick  the 
wart  with  a  sharp  curette.  Another  painless  method  consists  in  cauterizing 
first  with  pure  carbolic  acid,  on  top  of  which  fuming  nitric  acid  is  applied. 
In  using  the  latter  caustic  method  the  surrounding  parts  should  be  pro- 
tected with  vaseline. 


GANGRENE.  gg^ 

Burns  (Combustio). 

We  frequently  see  burns  of  various  degrees  in  children. 

Causes. — They  are  usually  caused  by  hot  water,  steam,  acids,  or  alka- 
lies. 

Symptoms. — An  intensely  inflamed  area  surrounding  a  blistered  sur- 
face is  usually  found.  Pain  and  sometimes  shock  is  noted.  In  some  cases 
fever  and  a  rapid  increase  in  the  pulse  are  noted.  A^iolent  reaction  such 
as  convulsions  frequently  occur  in  weak  and  rachitic  children  if  a  severe 
burn  has  taken  place. 

Prognosis. — This  depends  upon  the  amount  of  surface  involved  and 
on  the  condition  of  the  child  at  the  time  of  the  accident.  Some  children 
survive  extensive  burns  with  good  care.  As  a  rule  a  cautious  prognosis 
should  be  given,  owing  to  the  risk  of  infection  and  danger  of  sliock. 

Treatment. — Strict  asepsis  should  govern  the  opening  of  all  blisters. 
Cornstarch,  wheat  flour,  europhen,  or  dermatol  may  be  used  locally.  In 
addition  thereto  linseed-oil  and  lime  water  or  calamine  and  zinc  lotion 
(see  chapter  on  "Eczema")  is  very  valuable.  Nutrition  forms  the  most 
important  part  of  the  restorative  treatment. 

Gangrene  (Superficial  Gangrene). 

This  condition  affecting  the  skin  or  extending  to  the  deeper  structures 
is  characterized  by  a  bluish  black  discoloration  resembling  a  deep  form  of 
cyanosis. 

Causes. — It  is  a  destructive  condition  following  the  acute  infectious 
diseases,  especially  scarlet  fever  or  measles.  Traumatism  or  pressure  inter- 
fering with  the  circulation  of  the  blood  or  robbing  the  extremity  of  its 
nutrition  may  result  in  a  destructive  gangrene.  The  following  case  of 
traumatic  gangrene  occurred  in  my  practice ;  it  was  a  traumatic  gangrene 
due  to  interference  with  the  circulation:- — • 

Baby  A.,  ten  moiillis  old,  breast-  and  bottle-fed,  was  referred  to  me  by  Dr.  A. 
Meyer.  I  found  a  temperature  of  10.5°  F.,  pulse  180,  respiration  60.  There  was  com- 
plete consolidation  of  one  lobe  of  the  left  side.  Bronchial  breathinj^  was  plainly 
heard  and  there  was  dullness  on  percussion. 

The  diagnosis  of  lobar  pneumonia  was  made.  With  the  aid  of  cold  packs  and 
small  doses  of  strychnine,  the  child's  condition  improved.  As  I  left  the  city  the  case 
was  treated  by  Dr.  Khodoff,  who  gave  me  the  following  memoranda: — • 

"The  nurse  administered  a  high  rectal  enema  by  suspending  the  child  with  a 
towel  around  the  thighs.  The  circulation  was  thereby  interfered  with.  I  believe  the 
thrombosis  which  appeared  at  about  the  saphenous  opening  was  of  traumatic  origin 
due  to  this  interference  of  the  circulation.  The  course  of  the  gangrene  was  as 
follows:  A  bluish  purple  spot  aboiit  the  size  of  a  ten-cent  piece  appeared  at  the 
saphenous  opening.  The  child  previous  to  this  showed  indications  of  pain.  It  was 
fretful,  tossing  about,  and  very  restless.  Th»  gangrenous  area  increased  on  the 
following  day.    It  was  decided  to  wait  for  a  line  of  demarcation  as  the  child  appeared 


882 


DISKASES    OF    THE    SKIN. 


to  be  in  a  state  of  collapse.  On  the  third  day  after  the  first  sign  of  gangrene 
appeared  a  rapid  spreading  look  place  upward  along  Poupart's  ligament  and  con- 
tinued above  and  involved  tlie  umbilicus." 

■When  I  again  saw  this  case  tlic  gangrene  involved  tJic  whole  abdomen.      The 
temperature  was  102°  F.,  the  pulse  very  feeble,  and  the  child  in  a  state  of  collapse. 


Bate. 

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-  — 

-J 

Fig.  2S9. — Case  of  Gangrene  Following  Lobar  Pneumonia.  Gangrene 
appeared  on  the  tenth  day  of  disease,  due  to  a  careless  metliod  of  suspending 
the  child  by  a  towel  aroinid  the  thighs,  which  resulted  in  throfnbosis,  ending 
fatally.     (Original.) 


It  was  necessary  to  stimulate  and  feed  per  rectum.      The  child  did  not  respond  to 
treatment  and  died  in  convulsions. 

Progrnosis. — The  prognosis  is  always  bad,  althouoh  surgery  may  bo 
tlie  means  of  amputating  a  gangrenous  extremity  and  saving  the  rest  of 
tlie  body. 

Treatment. — Tlicre  is  no  medicinal  treatment  worth  trying.  Surgical 
relief  is  our  only  hope. 


sYi[:\rETRirAL  gangrene. 


,SS3 


Symmetkical  ({ax(u;j:\e  (Kayxalu's  Disease). 

This  is  an  oljsciire  coiiilitioii  in  wliicli   the  gangrene  is  symmetrical. 

Etiology. — It  is  caused,  no  doubt,  by  the  invasion  of  pathogenic  bac- 
teria. Infectious  diseases  wliich  devitalize  the  body  are  believed  to  pro- 
dispose  to  this  condition.  Injury  and  haemorrhages,  such  as  epistaxis,  have 
])e('n  forerunners  of  this  condition. 

Symptoms. — When  acute  there  is  fever  and  enlargement  of  the  spleen, 
luvmaturia,  or  ha?moglobinuria.  The  affected  part  feels  cold  and  appears 
bluish ;  sometimes  there  are  vesicles  containing  a  sero-purulent  fluid.  This 
condition  lasts  from  two  to  three  weeks,  although  it  may  extend  over  manv 
months.  The  disease  ends  in  mummification  and  gradual  decay  of  the 
affected  parts.  The  toes,  fingers,  ears,  or  tip  of  the  nose  may  be  the  seat 
of  this  affection. 

Prognosis. — A  cautious  prognosis  should  always  be  given.  While 
records  of  cures  exist,  the  diagnosis  may  always  ])e  questioned. 

Treatment. — General  restorative  treatment,  concentrated  foods,  and 
hygiene  should  form  the  basis  of  treatment.  The  skill  of  the  surgeon  nuiy 
eradicate  the  gangrenous  parts. 

Scabies. 

This  is  a  contagious  disease  caused  by  the  female  acarus  burrowing  into 
the  skin.  The  characteristic  features  of  this  disease  are  that  it  is  found 
between  the  fingers,  in  the  axilUv,  on  the  flexor  surfaces  of  the  wrists,  ant  I 
also  around  the  genitals.  The  eruption  is  either  a  papule,  or  a  vesicle,  some- 
times a  pustule.  There  is  an  intense  itching,  and  secondary  infection 
results  from  scratching.  Several  children  in  the  same  family  will  usually 
he  found  so  affected. 

The  prognosis  is  always  good  providing  thorough  treatment  is  instituted. 

Treatment. — A  hot  bath  to  thoroughly  soak  the  body  and  soften  the 
epithelial  scales,  should  be  ordered.  An  inunction  of  ^/.j  unguentum 
liydrarg.,  -/a  vaseline  should  follow  the  bath.  Sulphur  soap  may  be  used  in 
addition  to  sulphur  ointment  if  no  benefit  results  from  the  foregoing 
treatment. 


CHAPTER  IV. 

ABNORMAL  GROWTHS  OCCASIONALLY  MET  WITH  IN  CHILDREN.' 

Abnormal  growths  are  frequently  seen  in  children.  Some  of  these 
are  malignant,  Avhile  some  are  I^enign.  We  must  not  suppose  that  children 
do  not  have  malignant  disease.  I  have  seen  malignant  sarcoma  involving 
the  whole  of  the  left  lung  which  crowded  the  heart  into  the  right  axillary 
space. 

Spindle-cell  Sarcoma  of  the  Thorax.^ 

Gustav  L.,  a  male  child  of  about  8  years,  was  first  seen  by  me  in  July,  1900. 
His  mother  gave  the  following  history: — 

He  was  breast-fetl  about  ten  Aveeks  and  owing  to  a  diminution  in  the  quantity 
and  quality  of  her  milk,  she  was  forced  to  wean  the  child.  He  then  received  sterilized 
milk.  This  food  was  given  until  the  child  was  weaned  from  the  bottle  at  about  the 
end  of  Ids  second  year. 

^^'hen  about  six  months  of  age,  a  large,  glandular  swelling  commenced  behind 
the  right  ear,  which  necessitated  an  incision.  The  attending  physician  said  it  was 
an  abscess.  At  this  same  time,  he  had  a  severe  attack  of  gastric  fever.  This  required 
careful  dietetic  treatment.    Cow's  milk  was  continued  in  a  more  modified  form. 

At  age  of  1  year  the  child  was  attacked  with  measles,  accompanied  by  a 
catarrhal  bronchitis.  Some  cough  remained  and  when  tlie  child  was  2  years  old  he 
had  a  severe  attack  of  pertussis.  When  the  child  recovered,  he  remained  well  imtil 
he  was  3  '/j  years  old,  then  he  was  infected  with  scarlet  fever  lasting  two  montlis. 
Thus  the  ciiild  passed  his  infancy  with  some  gastric  derangement,  followed  by  measles, 
pertussis,  and  scarlet  fever.     He  did  not  have  croup  or  diphtlicria. 

"Family  Histori/. — This  is  good.  The  parents  of  this  patient  are  both  living,  and 
apparently  strong  and  healthy;  they  have  two  other  boys,  well  and  strong.  There  is 
no  history  of  syphilis,  rheiunatism,  gout,  tuberculosis,  epilepsj',  nor  anything  of  a 
malignant  nature  in  the  family,  excepting  this  fact  which  is  extremely  noteworthy, 
that  the  grandfather  had  a  sarcomatous  tumor,  wliich  ended  fatally. 

"E-nnnindtiou. — The  patient  was  brought  to  me  for  the  relief  of  a.  number  of 
tumors  on  the  front  of  the  thorax,  which  felt  quite  hard  on  palpation.  At  times  a 
distinct  sense  of  fluctuation  could  be  made  out,  and  when  examined  by  an  exploratory 
puncture,  a  few  drops  of  thin,  yellowish  serum  was  obtained.  These  tumors  have 
been  very  troublesome  for  the  pa.st  few  years.  They  have  caused  severe  dyspnoea. 
The  physician  who  treated  this  boy  in  Hamburg  believed  that  the  growths  contained 


^  For  comjdete  list  surgical  works  should  be  consulted. 

-  Head  before  the  Section  on  Pediatrics^  the  New  York  Academy  of  Medicine, 
April  10,  1902. 
(884) 


SARCOMA    OF    THE    THORAX. 


885 


pus.  This  statement  was  made  to  the  family.  Tlie  physician  made  an  exploratory 
puncture  and  was  rewarded  by  a  few  drops  of  thin,  serous  liquid,  as  in  a  puncture  I 
nrnde  and  obtained  no  pus. 

"The  size  of  the  growth  as  seen  externally  is  about  15  centimeters  in  length 
and  about  6  to  7  centimeters  in  circumference.  (See  Fig.  290.)  There  is  marked 
dullness  on  percussion  extending  over  most  of  the  left  side.  Tiie  tumor  is  surrounded 
by  a  network  of  veins,  intensely  engorgetl  with  blood.  There  is  mediastinal  pressure. 
As  far  as  can  be  seen  and  palpated,  the  growth  occupies  that  region  of  the  thorax 
usualhi  occupied  hij  the  heart.     The  growth  varies  in  size  from  week  to  week. 

'"The  heart  has  been  pushed  to  the  right  side  and  occupies  the  right  axilla.  The 
apex  beat  is  heard  about  two  finger  breadths  below  and  to  tiie  right  of  the  right 
n  ipple.      { See  figure  291.) 

'"The  pulse  is  144,  small,  feeble,  quite 
irregular  and  easily  compressible.  The 
respiration  is  irregular,  of  the  Clieyne- 
Stokes  type,  and  frequently  sighing.  It 
is  usually  about  50-52  in  a  minute;  the 
temperature  is  always  above  normal  and 
varies  from  100°  F.  in  the  rectum,  morn- 
ing, to  101  -/^°  in  the  evening.  There  is 
ahvays  a  febrile  tendencj'. 

"There  is  constant  dyspnoea  and  also 
extreme  cyanosis  of  the  lips^  fingers  and 
toes.  The  child  is  very  pale  and  in  a 
very  anaemic  condition.  There  is  extreme 
pallor  of  the  conjunctival  membrane,  the 
gums,  and  the  mucous  membrane  of  the 
lips." 

Owing  to  the  extreme  amomit  of 
weakness  caused  by  anorexia,  the  child 
was  compelled  to  remain  in  bed  most  of 
the  time  for  the  last  year.  Dyspna'a  was 
so  great  that  the  child  slept  in  a  sitting 
posture.  The  child  was  very  nen'ous  and 
trembled  when  he  was  touched.  He  was 
very  bright  mentally.  There  was  con- 
stant and  rapid  emaciation.  Concen- 
trated food  was  given,  which  the  patient 
took  quite  well.  There  was  extreme 
hypersesthesia  of  the  skin.  The  digestion 
was  quite  good,  and  although  the  bowels 
moved  sluggishly,  they  did  not  require 
much  medicinal  treatment.  Fruit  and  fruit  juices  acted  a.s  laxatives.  Tliere  was  a 
cuiTature  of  the  spine  from  left  to  right,  most  marked  in  the  dorsal  vertebra.  Tli<- 
mine  was  examined  several  times.  It  showed  no  evidence  of  pus  or  blood,  no 
albumin  and  no  sugar.  There  was  a  slight  indie  an  reaction.  No  acetone,  no  casts, 
no  morphotic  elements.  microscopi<'ally. 

The  case  was  hopeless  from  a  medical  standpoint,  as  the  growth  was  constant^- 
increasing.  The  child  suflVred  constantly  fiom  insomnia  and  great  dyspncra,  requir- 
ing constant  soporifics  and  narcotics.  In  spite  of  the  grave  prognosis,  the  family 
hoped  that  surgical  measures  might  afford  some  relief. 


Fig.  200. — Spindlc-cell  Sarcoma, 
The  prominence  of  the  tumor  shows 
by  contrast  the  emaciation  of  the 
body.     (Original.) 


886 


ABNOm^L■VL    GROWTHS. 


As  the  tumor  frequently  appears  to  show  a  distinct  pointing,  this  latter 
condition  suggesting  lluid,  an  anttsthetic  was  given  with  the  assistance  of  Dr.  J.  W. 
Wurthman.  The  anaesthetic  was  badly  borne  and  I  succeeded  with  difficulty  in 
making  two  exploratory  punctures. 

An  x-ray  examination,  to  verify  the  clinical  data,  was  made  by  Dr.  C.  Beck,  to 
whom  the  case  was  referred.     The  heart  couhl  be  plainly  seen  pulsating  on  the  right 


Fig.  291. — Anterior  \'ie\v  of  the  Tumoi.     ,-.iii>,.  in- 
displaced  heart  and  the  enlarged  veins. 


1I-.U  the   position  of  the 
(Original.) 


side.  No  definite  satisfactory  data  could  be  learned  concerning  the  tumor,  on 
account  of  the  restlessness  of  the  patient,  and  tlie  child  was  removed  to  St.  Mark's 
Hospital  and  operated.    The  child  died  soon  after  the  operation. 

A  specimen  of  the  tumor,  removed  during  the  operation,  was  sent  by  me  to  Dr. 
Mandlebaum,  for  a  pathologic  examination,  lie  roporteil  the  tumor  to  be  a  spindle 
cell  sarcoma  in  a  rather  active  state  of  growth,  on  account  of  the  large  number  of 
mitoses  present.     The  fluid  contained  simply  red  blood  cells  and  no  pus. 


ENCHOJ^DRO^iIATA.  887 

Sarcomatous  growths  in  children  are  quite  rare,  though  met  with  from 
time  to  time.  Thus  Mauderh,  in  the  Children's  Hospital  of  Basle,  Swit- 
zerland, reports  for  the  last  twenty  years  that  he  treated  a  total  of  lU 
patients:  7  bo^s  and  3  girls,  of  whom  4  were  under  3  years  of  age,  3  were 
between  3  and  G  years,  1  was  between  G  and  9  years,  and  2  were  between 
9  and  12  years. 

As  but  one  case  of  malignant  sarcoma  was  met  with  in  this  hospital 
in  the  course  of  the  last  twenty  years  in  children  as  old  as  the  case  here 
reported  by  me,  I  feel  justified  in  adding  mine  to  those  already  recorded. 

The  interesting  points  about  my  case  were:  (1)  The  displaced  heart — 
the  heart  being  immediately  behind  the  right  nipple.  The  pulsations  and 
apex-beat  could  be  distinctly  felt  and  seen  about  two  finger-breadths  below 
the  right  nipple.  (2)  The  intense  dyspnoea  caused  by  pressure  of  the 
tumor,  (3)  Constant  cyanosis  and  cedema  of  the  limbs,  due  to  interfer- 
ence with  the  return  circulation  to  the  right  side  of  the  heart. 

Caucixoma. 

Carciiiunia  is  occasionally  found  in  children.  Malignant  growths  of 
this  kind  have  been  diagnosed  and  verified  by  microscopical  examinations. 

Lipoma. 

Fatty  growths  are  occasionally  seen  in  children.  They  occur  on  the 
scalp,  on  the  back,  and  I  have  seen  them  on  the  buttocks.  They  require 
the  same  treatment  as  fatty  growths  in  adults.  (See  article  in  the  "New- 
born Baby"  on  ''Congenital  Sacral  Tumor.") 

E  XCHOXDROMATA. 

These  hard  growths  are  usually  found  on  the  fingers  and  toes.  They 
are  found  in  the  neighborhood  of  the  joints  with  which  they  are  closely 
allied.  A  case  of  this  kind  which  had  several  tumors  removed,  occurred  in 
my  practice : — 

Mary  B.,  10  years  old. 

Family  Histori/. — Father  liealtliy.  Mother  died  of  carcinoma  of  the  uterus. 
Has  one  sister  who  is  healthy  and  married. 

I'dfinit'n  ffistoii). — Was  breast-fed  duriiii:  infancy.  Snflered  with  no  gastric 
or  enteric  disorders.  Had  measles  when  several  years  old.  Is  not  subject  to  any 
chronic  disease.  Her  extremities  are  normal  excei)tinf»  the  affected  hand.  The 
mother  stated  tlie  tumors  had  been  prc^sent  soon  after  birth.  Tliey  were  not  ])ainfui 
nor  did  they  cause  discomfort,  so  notliiii}^  was  done  until  tlic  child  reached  this  acfe. 
The  case  was  referred  by  me  to  the  sur<iri<'al  service  of  Dr.  S.  .M.  F.andsman,  wlio  re- 
moved the  growths.     The  case  made  a  i)erfect  recovery. 


888 


ABNORMAL    GROWTHS. 


Spina  Bifida. 

Abnormal  growths  are  frequently  found  in  the  lumbar  region  asso- 
ciated with  the  spinal  cord.     They  are  frequently  seen  in  cases  of  hydro-    j 
cephalus.    A  case  of  spina  bifida  is  reported  in  the  chapter  on  "Malforma-    { 
tions  of  the  >Spine." 

Angeioma. 

ArKjeioma. — Large  vascular  growths  are  occasionally  seen  in  children. 
A  case  of  this  kind  was  seen  by  me.  which  I  describe  in  the  chapter  on  the 
''New-Born  Baby,"  i)age  53. 


Fig.  292. — Knehondromata  Tiivf)]viii<i;  tlie  Tlmmb  and 
Index  Finger.      (Orioinal.) 


PAl'ILLO:\rATA. 

This  growth  is  occasionally  seen  in  the  larynx  of  infants  and  children. 
It   may  be  congenital. 

Symptoms. — Marked  dyspncea  is  usually  a  prominent  symptom.  This 
dyspnoea  increases  with  the  enlargement  of  the  growth.  There  is  also  a 
husky  voice,  which  increases  in  severity.  The  symptoms  are  very  marked 
at  night,  but  are  much  less,  and  fre(|uently  disappear  entirely,  during  the 
day.  Cough  may  also  be  present,  but  no  expectoration.  There  is  no  fever. 
The  diagnosis  is  usually  made  by  a  laryngoscopic  examination.  When  the 
same  symptoms  appear  for  weeks  and  months  a  laryngeal  growth  should' 
be  suspected. 

Treatment. — T?omoval  r)f  the  growth  with  an  anaesthetic  is  absolutely 
necessary.     The  danger  in  removing  the  growth  should  always  be  borne  in 


GRANULOMATA.  8§9 

niiiid,  hence  the  surgeon  should  be  prepared  to  perform  a  tracheotomy  if 
necessary.  Intubation  of  the  larynx  will  relieve  the  difficult  breathing;  at 
the  same  time  there  is  danger  of  pushing  some  of  this  growth  with  the  tube, 
thus  obstructing  the  caliber  of  the  same.     Eelapses  are  common. 

Gkanulomata.i 

These  growths  are  frequently  seen  at  the  site  of  the  wound  following  a 
tracheotomy.     They  resemble  a  mass  of  exuberant  granulations. 

Prof.  A.  Eosenberg,  of  Berlin,  collected  .331  cases  of  laryngeal  tumors 
in  cliildren.  Some  of  them  were  subjected  to  tracheotomy,  others  received 
endo-laryngeal  treatment  preceded  by  tracheotomy.  In  another  series  of 
cases  persistent  endo-lar3^ngeal  treatment  was  resorted  to  without  perform- 
ing tracheotomy.     This  latter  method  yielded  the  better  results. 


^In  Part  II.,  Page  33,  will  be  found  article  on  "Gianulonia." 


PART  XL 

DISEASES  OF  THE  SPINE  AND  JOINTS. 


PoTi''s  Disease.^ 

This  disease  derives  its  name  from  Percival  Pott,  who  described  it 
in  1779.  ''It  is  a  chronic  destructive  process  wliich  begins  in  the  bodies 
of  the  vertehrae.  The  bodies  of  the  vertebra?  support  the  weight  of  the  body. 
As  the  disease  progresses  the  weakened  parts  give  way,  and  the  upper  seg- 


Fig.  293.— Pott's  Dis- 
ease (Langeihans) .  Ky- 
phosis of  dorsal  vertebrse, 
the  result  of  caseous  tu- 
berculous periostitis  and 
osteomyelitis.  Destruc- 
tion of  three  thoracic  ver- 
tebrae. Two-thirds  nat- 
ural size. 


ment  inclines  forward.  An  anguhir  posterior  projection,  l-yphosis,  is 
formed  which  is  the  characteristic  deformity  of  the  disease." 

Etiology. — "Pott's  disease  may  appear  at  any  period  of  life,  from 
earliest  infancy  to  old  age,  l)ut  like  all  forms  of  tuberculosis  of  the  bones, 
it  is  most  coiniiion  in  the  first  ten  years  of  life,  and  50  ])er  cent,  of  the 
cases  begin  between  the  ages  of  3  and  5  years,  inclusive. 

"The  lower  segment  of  the  spino,  int-hiding  the  dorso-luiiibar  region, 
is  most  often  involved.     C'ervical  disease  is  relatively  iiifn^(ii]ent  (cervical. 


'  The  table  of  diflFerential   points  between   Pott's  Disease  and   Rickets  will   be 
found  on  page  356. 
(890) 


POTT •«    DISEASE.  §91 

7  V2  per  cent.;  dorsal,  G8  per  cent.;  lumbar,  2-i  per  cent.).  The  death 
rate  is  at  least  35  per  cent.  The  course  of  the  disease  is  most  protracted  in 
the  middle  region;  it  is  shortest  in  the  cervical  region,  its  duration  vary- 
ing in  favorable  cases  from  two  to  five  years. 

"When  the  local  resistance  overcomes  the  tendency  to  degeneration, 
the  process  of  repair  begins.  The  tuberculous  products  are  absorbed  or 
enclosed,  and  ankylosis  between  the  two  segments  of  the  spine  is  estab- 
lished by  means  of  a  union,  in  part  librous,  cartilaginous,  and  bony.  Firm 
union  is  long  delayed,  and  the  deformity  may  increase  long  after  the 
disease  has  become  inactive"    (Whitman). 

Pathology  and  Bacteriology. — "The  first  indications  of  disease  are 
most  often  found  beneath  the  fibro-periosteal  layer  of  the  anterior  longi- 
tudinal ligament.  From  this  point  the  granulation  tissue  advances  along 
the  course  of  the  blood-vessels  into  the  adjacent  bone,  extending  from 
one  to  another  until  several  bodies  are  more  or  less  involved.  The  disease 
is  accompanied,  in  many  instances,  by  an  abscess,  which  may  be  of  suffi- 
cient size  to  cause  special  symptoms;  or  the  tuberculous  process  may  find 
its  way  to  the  posterior  part  of  the  vertebral  bodies  and  thus  involve  the 
bpinal  cord,  causing  paralysis.  Abscess  is  most  common  as  a  complication 
of  disease  of  the  lower  part  of  the  spine,  where  it  may  be  detected  in  at 
least  50  per  cent,  of  the  cases.  Paralysis  most  often  complicates  disease 
of  the  upper  dorsal  region,  appearing  in  about  10  per  cent,  of  the  cases 
in  which  this  part  of  the  spine  is  involved.  The  primary  infection  is  no 
doubt  due  to  the  entrance  of  the  tubercle  bacillus.^' 

Anatomical  Landmarks. — "The  atlas  is  on  a  line  with  the  hard  palate. 
The  axis  is  on  a  line  with  the  free  edge  of  the  upper  teeth.  The  transverse 
process  of  the  atlas  is  just  below  and-  in  front  of  the  tip  of  the  mastoid 
process.     The  hyoid  bone  is  opposite  the  fourth  cervical  vertebra. 

"The  cricoid  cartilage  is  on  a  line  with  the  sixth  cervical  vertebra. 

"The  upper  margin  of  the  sternum  is  opposite  the  disc  between  the 
second  and  third  dorsal  vertebrae. 

"The  junction  of  the  first  and  second  sections  of  the  sternum  is  op- 
posite the  fourth  dorsal  vertebra. 

"The  tip  of  the  ensiform  cartilage  is  opposite  the  lower  part  of  the 
body  of  the  tenth  dorsal  vertebra. 

"The  anterior  extremity  of  the  first  rib  is  on  a  line  Avith  the  fourth 
rib  at  the  spine,  the  second  with  the  sixth,  the  fifth  witli  tlie  ninth,  the 
seventh  with  the  eleventh. 

"The  scapula  covers  the  second  and  the  seventh  ribs,  its  lower  angle 
being  op])ositc  the  center  of  the  eighth  dorsal  vertebra. 

"The  root  of  the  spine  of  the  scapula,  the  glenoid  cavity,  and  the 
interval  l)etween  tlie  second  ;md  iliii'd  dorsal  spines  are  in  the  same  ])lano. 

"The  most  constant  landmark   from  which   to  count  is  the  spinous 


g92  DISEASES    OF    THE    SPINE    AND    JOINTS. 

process  of  the  fourth  lumbar  vertebra,  which  is  on  a  line  with  the  highest 
point  of  the  crest  of  the  ilium.     The  umbilicus  is  near  the  same  plane. 

"The  tip  of  the  coccyx  is  opposite  the  lower  border  of  the  symphysis 
pubis." 

Symptoms. — If  the  upper  ])art  of  the  spine  is  alfected,  a  stiffness  of 
the  neck  usually  exists.  If  tlie  lower  })art  of  the  spine  is  affected,  limping 
will  be  noticed,  hence  awkwardness  in  walking  in  very  antemic  children 
should  always  be  looked  upon  as  suspicions. 

"The  limitation  of  motion  due  to  muscular  spasm,  to  pain,  and  to  the 
local  disease  is  an  important  factor  in  diagnosis.  This,  together  with  the 
deformity,  may  be  demonstrated  l)y  bending  the  patient's  body  directly 
forward  to  the  fullest  extent.  An  object  is  next  placed  on  the  floor,  and 
the  patient  is  directed  to  pick  it  up.  If  this  is  done  awkwardly  by  squat- 
ting or  kneeling,  it  demonstrates  weakness  and  stiffness.  The  patient 
should  next  be  placed  prone  upon  a  table,  and  the  surgeon  should  test  the 
flexibility  of  the  spine  by  lifting  the  legs  and  swaying  the  body  from  side 
to  side.  The  range  of  extension  at  the  hips  may  be  tested  at  this  time  by 
liolding  the  pelvis  against  the  table  with  one  hand,  while  the  thigh  is  over- 
extended with  the  other.  This  is  the  test  for  the  slight  degree  of  psoas 
contraction  that  is  often  present  on  one  or  both  sides  in  disease  of  the 
lower  region. 

"The  flexibility  of  the  upper  })art  of  the  spine  may  be  tested  by  vol- 
untary and  passive  movements  of  the  head  in  various  directions,  and  the 
range  of  motion  of  the  occipito-atlo-axoid  joints  by  holding  the  neck  while 
the  patient  nods  and  turns  the  head  from  side  to  side. 

"The  character  and  the  extent  of  the  deformity,  if  it  be  present,  should 
next  be  investigated.  Xote  the  contour  of  the  spine.  Any  change  from 
the  normal  are,  in  childhood,  suspicious  circumstances.  Note  the  elastic- 
ity of  the  spine.  If  when  the  child  is  bent  forward  the  spine  forms  a  long, 
regular,  even  curve,  disease  is  unlikely.  If  there  be  a  break  in  the  outline, 
and  if  one  part  remains  rigid  and  another  bends,  disease  may  be  suspected."' 

Pott's  disease  in  the  lower  region  of  the  spine  presents  the  following 
characteristics : — 

1.  Pain. — The  pain  is  referred  to  the  lower  part  of  the  abdomen,  to 
the  genitals,  to  the  loins,  or  to  the  thighs. 

2.  Gdit. — The  waddling  gait  which  has  been  described  under  general 
symptomatology  is  characteristic  of  disease  in  this  region.  In  some  cases 
there  is  a  limp. 

3.  Attitude. — Usually  an  abnormal  erectness  and  sometimes  an  ex- 
aggerated lordosis;  in  some  instances  a  lateral  inclination  of  the  body. 
Unilateral  psoas  contraction  and  the  attendant  limp  are  often  present. 

4.  Stiffness.  —  Muscular  rigidity  of  the  lumbar  region  interferes 
directly  with   almost  every   attitude   and   movement.      The   effect  of   this 


POTT'S    DISEASE. 


sya 


stiffness  and  of  the  accompanying  weakness  may  be  demonstrated  by  the 
})opular  method  of  asking  the  child  to  pick  up  a  coin  from  the  floor.  In 
this  region  of  the  spine  the  symptoms  are  usually  well  marked  before  the 
stage  of  deformity,  Hexion  of  the  legs,  the  effect  of  psoas  contraction,  and 
abscess  are  present  in  perhaps  a  third  of  the  cases. 

Pott's  disease  of  the  middle  region  is  characterized  by  the  following 
peculiarities : — 

1.  Pain  is  referred  to  the  lateral  region  of  the  thorax  or  to  the  front 
of  the  body.  It  is  a  common  symptom.  It  is  noted  after  sudden  move- 
ments or  after  compressing  the  chest,  as  when  the  child  is  suddenly  lifted 
from  the  floor. 

3.  Respiration. — If  the  disease  is  at  all  active,  a  grunting  respiration 
is  usually  present,  especially  after  exertion.  This  is  the  most  characteristic 
of  all  symptoms,  especially  so  in  young  subjects. 

3.  Attitude. — This  is  not  always  distinctive,  but  usually  there  is  a 
peculiar  shrugging  squareness  of  the  shoulders;  occasionally  a  lateral  in- 
clination of  the  body.  The  head  is  often  inclined  backward.  The  neck 
seems  short  on  account  of  the  elevation  of  shoulders. 

4.  Deformity. — The  deformity-  is  usually  prominent  and  it  appears 
early  in  the  disease. 

5.  Complications. — The  most  common  complication  of  dorsal  disease 
is  paralysis,  abscess  being  less  frequent  than  in  the  lumbar  region.  Flat 
chest  and  chicken  breast  may  be  secondary  deformities. 

Pott's  disease  of  the  upper  region  presents  the  following  peculiari- 
ties : — 

1.  If  the  uppermost  cervical  vertebra?  are  diseased,  the  pain  is  referred 
to  the  head,  particularly  to  its  lateral  and  posterior  aspects.  In  disease  of 
the  middle  cervical  region  it  is  referred  to  the  neck,  or  to  the  shoulders 
or  chest. 

2.  The  wealmess  and  stiffness  are  manifest  by  the  attitude.  The  head 
cannot  be  turned  freely.  If  the  disease  be  in  the  occi])ito-axoid  region, 
the  nodding  and  rotary  motions  are  restricted.  The  cliin  is  often  de])ressed 
and  slightly  turned  to  one  side.  Lateral  distortion  resembling  torticollis 
usually  occurs  when  disease  is  nearer  the  middle  of  tlie  cervical  region. 

3.  The  Ijony  (IrfonDiiij  is  often  sliglit  or  aljscnt,  but  thickening  of  the 
tissues  about  the  spine  and  local  sensitiveness  to  lateral  ])ressure  are  usu- 
ally present.  Hetro-pharyngeal  abscess  is  not  uncommon  when  the  atlo- 
axoid  region  is  involved. 

Complications. —  (a)  Abscess;  (b)  Paraljjsis:  About  "25  per  cent,  of 
all  cases  have  abscess.  An  abscess  situated  in  the  atlo-axoid  region  often 
burrows  into  the  retro-pharyngeal  space.  It  may  involve  the  cranial  cavity 
when  this  occurs;  symptoms  of  meningitis  will  be  noticed.  When  an 
abscess  forms  from  disease,  of  the  middle  cranial  region  it  usually  opens 


894  DISEASES    OF    THE    SPINE    AND    JOINTS. 

on  tlio  side  of  the  neuk,  before  or  beliiud  the  sterno-eleido  mastoid  region. 
^\■hen  altscess  follows  disease  in  the  dorsal  region  it  burrows  through  the 
thorax.  It  ean  Ije  deteeted  by  the  })hysie'al  signs  aceoinpan^'ing  pain  (see 
chapter  on  "Eiuj)yenui"). 

When  it  burrows  downwai'd  it  may  give  rise  to  an  iliac  or  lumbar  ab- 
scess. "In  disease  of  tlie  lumbar  region,  the  abscess,  if  superficial  to  the 
ilio-psoas  muscle,  nuiy  ])oint  in  the  neigb])orliood  of  the  anterior  superior 
spine,  or  ])as8  through  the  inguinal  ring.  The  true  psoas  al)scess  first  dis- 
tends the  iliac  region,  and  then  passing  into  the  thigh,  appears  in  Scarpa's 
space.  In  large  abscesses  of  this  character  the  pus  may  find  an  exit  in  the 
loin  at  the  triangle  of  Petit,  or  in  the  gluteal  region  through  the  sacro- 
sciatic  foramen. 

'Tn  rare  instances  the  abscess  may  find  an  opening  within  tlie  body, 
and  l)urst  into  Ihe  lungs,  the  intestines,  or  elsewhere. 

"As  a  rule  abscess  causes  but  little  difficulty  in  diagnosis,  because  it  is 
a  late  symptom,  appearing  after  the  diagnosis  of  Tott's  disease  has  been 
established.  It  is  more  often  an  early  symptom  in  the  upper  and  lower 
regions  of  the  spine,  but  in  any  event  it  is  always  accompanied  by  symp- 
toms of  the  underlying  disease  of  the  spine." 

ParaJj/sls.—ThQ.  symptoms  of  Pott's  paralysis  are  '"an  awkward  stumb- 
ling gait,  weakness,  and  iinally  an  inability  to  stand.  The  lower  limbs  are 
"stilP  at  times.  The  reflexes  are  increased.  C'ontrol  of  the  bladder  may  be 
retained,  but  often  there  is  active  incontinence;  that  is,  the  bladder  emp- 
ties itself  from  time  to  time,  if  the  pressure  is  directly  upon  the  reflex 
centers  in  the  lumbar  enlargement,  there  may  be  passive  incontinence  or 
dribbling  of  urine.  If  the  pressure  is  below  the  reflex  centers,  the  bladder 
is  not  affected,  and  the  symptoms  of  numbness  and  weakness  resemble  those 
caused  by  neuritis." 

Differential  points  concerning  abscess: — 

1.  Abscess  of  the  cervical  region  must  not  be  confounded  with  the 
symptoms  of  enlarged  tonsils,  adenoids,  or  with  so-called  croup.  It  must 
also  be  distinguished  from  the  simple  acute  abscesses  of  this  region. 

2.  Abscess  of  the  thoracic  region  is  to  be  distinguisTied  from  those 
secondary  to  disease  of  the  lung  or  of  the  chest  wall. 

3.  Abscess  in  the  loin  or  inguinal  region  may  be  mistaken  for  the 
acute  or  chronic  abscess  due  to : — 


(a)  Perinephritis. 


(  These  are  usually  of  acute  onset  and  are  ac- 
(      conipanied  by  constitutional  disturl)anees. 
r  Tliere  may  be  secondary  rigidity  of  the  sjjine, 
(h)  Perityphlitis.  J       but  no  deformity,  as  is  usual  in  Pott's  dis- 

[^      ease  at  the  stage  of  abscess  formation. 

(c)  Sacral  or  iliac  disease.      The  symptoms  of  Pott's  disease  are  lacking. 

(d)  Hernia. 


POTTS    DISEASE. 


895 


The  paralysis  of  Pott's  disease  must  be  distinguished  from 

1.  Simple  weakness. 

2.  Injury  to  the  cord. 

3.  Tumors  of  the  cord. 

4.  S3'philitic  disease  of  the  cord. 

The  weal-ness  and  stiffness  caused  by  Pott's  disease  in  the  lower  region 
may  be  simulated  by  lumbago,  rheumatism,  sciatica,  and  by  the  effect  of 
injury  or  strain.  Lumbago,  rheumatism,  and  sciatica  are  uncommon  in 
childhood.     They  are  usually  of  sudden  onset.      Sciatica  is  usually  uni- 


Fig.  204.— Pott's  Disease.     Case  of  Harry  F.     (Oriprinal.) 


lateral;    the  pain  of  Pott's  disease  is  usually  bilateral.     Strains  and  other 
injuries  have,  as  a  rule,  a  well-defined  history. 

Prognosis. — This  should  I)c  oaiitionsly  given.  While  most  cases  seen 
by  me  ended  fatally,  several  cases  improved  and  recovered  entirely.  Years 
of  patient  treatment  are  necessary,  and  occasionally  ilie  most  severe  cases 
nuiy  end   in  reoov-ery. 

Harry  F.,  4  years  old. 

Familii  nixtori/. — Fatlier  and  niollior  are  iinlioaltliy,  weak  and  von*  poor.  One 
cliild  lias  died  of  summer  complaint.  Another,  two  years  younger,  is  inclined  to 
cougli,  and  was  operated  by  me  for  empyema. 


^96  DISEx\SES    OK    T11J-:    Sl'lNE    A]SJ)    JOINTS. 

l'cn<uiial  Hiatory. — Tlie  child  was  born  i>iul  lias  since  tiien  lived  in  a  tenemient 
Louse,  in  a  densely  j)opulatcd  section  of  the  city.  He  was  a  bottle-fed  infant,  and 
has  been  constipated  since  birth,  although  he  sutlers  with  diarrhoea  in  summer. 
Has  always  been  a  frail  and  sensitive  child.  Has  had  measles  and  bronchitis,  and 
is  constantly  troubled  witli  some  catarrhal  affection.  The  child  was  late  in  walking, 
late  in  talking,  and  late  in  dentition.  The  general  development  shows  backwardness 
when  compared  witli  a  normal  child.  A  slight  deformity  of  the  spine  was  first 
noticed  when  the  child  was  about  2  years  old.  It  has  increased  in  prominence  since 
that  time.  There  is  no  distinct  evidence  of  tuberculosis  that  can  be  made  out  in  the 
lungs.  The  glands  are  not  eidarged,  there  is  no  cough  or  expectoration.  No  evidence 
of  fever. 

77(C  treatment  consisted  in  giving  codliver-oil  and  creosotal  internally  from  2 
to  5  drops,  three  times  a  day.  Friction  of  the  body  and  general  hygienic  measures 
were  instituted.  Great  stress  was  laid  on  the  nourishment  of  the  body.  Cream, 
butter,  eggs,  cereals,  and  vegetables  have  been  given  constantly. 

Orthoixrdir  Treatment. — For  the  relief  of  the  deformity,  a  supporting  brace 
fitted  to  the  body  like  a  corset,  similar  to  a  Bradford  frame,  had  been  used  for  over 
six  months  with  little  im])rovement,  therefore  the  case  was  sent  to  Dr.  Ashley  for 
a  plaster-of-Paris  corset.  This  treatment  has  been  very  successful,  and  the  child 
is  progressing  favorably. 

Treatment.  —  A\'hen  pus  is  present  nothing  but  surgical  treatment 
should  be  considered.  Surgical  treatment  is  not  always  necessary.  The 
majority  of  cases  require  support  by  means  of  (a)  spinal  splint;  (h)  spinal 
brace;  (c)  plaster  jacket. 

Either  of  these  must  be  properly  applied  by  a  competent  surgeon.  J 
have  seen  some  very  disagreeable  accidents  due  to  a  too  tight  plaster  corset. 
For  details  in  connection  with  the  application  of  braces  or  plaster  jackets 
the  reader  is  referred  to  text-books  on  orthopa3dic  surgery. 

Medicinal  Treatment. — This  consists  in  giving  restoratives  such  as 
codliver-oil,  iron,  and  arsenic.  Creosotal  can  be  given  with  the  codliver- 
oil.  A  rigid  diet  such  as  cream,  butter,  milk,  cereals,  eggs,  vegetables,  and 
fruits  is  indicated. 

If  the  child  lives  in  the  city  a  change  to  the  seashore  or  to  the  moun- 
tains  will   sometimes   improve   tlie   chances   of   recovery. 

Flatfoot  in  Children. 

Children  are  not  born  flatfooted.  Very  heavv  cliildren  are  predis- 
posed to  flatfoot,  especially  if  rickets  is  present.  Laxity  of  the  knees  is 
usually  found  associated  with  this  condition. 

Treatment. — Careful  orthopjpdic  treatment  is  necessary.  This  usu- 
ally consists  in  wearing  a  properly  fitting  shoe  in  wliich  the  arch  is  sup- 
])orted  with  the  aid  of  a  stiff  steel  or  celluloid  plate.  At  times  a  soft  pad 
of  felt  only  is  necessary. 

Ji.  W.  TiOvett,  of  Boston,  has  contributed  to  the  literature  of  this 
subject,  and  the  reader  is  referred  to  his  writings  for  details  on  this  matter. 


LATERAL  CURVATL  RE  OF  THE  SPINE. 


897 


Lateral  Curvature  of  the  Spixe. 
A  very  frequent  coudition  seen  in  weak  children  is  curvature  of  the 


spme. 


Etiology. — Children  that  were  bottle-fed  in  infancy   and   especially 
those  having  rickets  usually  develop  this  condition.     Angemic  children  and 


Fig.  29.5. — Schoolgirl,  Showing  Lat-  Fig.     296. — Lateral      Curvature     of 

eral    Curvature    of    the    Spine,    Due    to-       Spine.     Same  girl.    Arms  folded.     (Orig- 
Faulty  Position.     (Original.)  inal.) 


those  with  flabby  and  atonic  luuscios  are  susceptible.     It  is  especially  due 
to  faulty  hah'ds  of  posture  in  the  sclioolroom. 

Symptoms. — Unless  the  cliild  is  undressed,  no  special  symptoms  may 
be  noticed.  At  times  a  difference  in  the  height  of  the  shoulders  and  in  the 
hips  will  be  apparent.  Pain  is  usually  absent,  although  T  liave  heard  chil- 
dren, especially  older  girls,  complain  of  backache  constantly. 

Prognosis. — This  is  usually  good. 

Treatment. — dymnastics  and  exercises  such  as  dumbbells  and  pulley 
weights  under  the  guidance  of  a  competent  instructor  will  usually  develo]) 


898  DISKASKS    OK    TllK    SPINE    AM)    .lOLNTS. 

the  special  niuselos  mid  con-eel  this  delormity.  Tlie  pedeiitavy  life  of  a 
boy  or  •i'irl  so  affected  slioiiid  lie  ciiaii^ed  to  an  outdoor  active  life.  The 
diet  should  he  largely  c()iii])osed  of  protcids,  such  as  meat,  milk,  c<j;iis,  and 
cereals,  ('(dd  s])on>iing  or  a  shower  l)alli  followcvl  hy  friction  of  tlu>  sur- 
face should  he  prescribed  daily.  Internally  stiTchnine  or  mix  vomica.  If 
the  patient  is  not  well-nourished,  butter,  cream,  codliver-oj],  and  malt 
extract  should  be  ordered. 

]\Iechanical  Appliances. — The  use  of  a  s])inal  brace  is  frequently  ad- 
vised. It  is  neither  scientific  nor  beneficial,  and  certainly  does  not  remedy 
this  condition. 

Morbus  Coxarius  (Hip-.ioixt  Disease :    Tubercular  Hip-joint 

Disease). 

Coxitis,  commonly  known  as  tubercidosis  of  the  hip-joint,  is  not  easily 
diagnosticated   in  the  primary  stage. 

The  age  is  no  hindrance  to  the  development  of  this  disease,  as  it 
usually   appears   between   the    (ifth    and    tenth    year. 

Coxitis  can  be  found  in  apparently  healthv  children,  showing  no  sign 
of  serofulosis. 

1.  They  coin])lain  of  tenderness. 

2.  Impediment  of  locomotion  of  the  affected  extremity. 

3.  The  change  of  the  position. 

4.  Local    changes    in   the   region   of   the   joint. 

Symptoms. — The  pain  is  one  of  the  earliest  symptoms  and  expresses 
itself  by  a  feeling  of  tenderness  in  the  affected  joint  or  in  the  knee.  The 
knee  is  quite  characteristic  in  this  affection  and  serves  a  good  center  for 
deception.  In  the  knee  no  changes  are  directly  noticeable;  there  is  no 
impediment  to  locomotion.  AVhen  the  ]iain  can  he  located  in  the  knee- 
joint  the  pathological  process  in  the  hip-joint  is  usually  fully  develojjcd. 
When  children  complain  of  ])ain  in  the  knee-joint  it  is  always  wise  to 
examine  the  hip.  One  of  the  most  characteristic  symptoms  is  the  in- 
varial)le  cry  at  night. 

The  child  will  cry  frequently  and  trill  suddenly  airal-en  at  flight,  with. 
pain  alony  the  thigh  not  pointing  to  a  distinct  spot,  hut  showing  that  the 
pain  is  diffused  aJong  tlie  leg;  this  symptoiu  is  rarely  absent  in  true 
coxitis. 

At  the  earliest  stage  of  coxitis  the  ])ain  is  trivial,  but  instinctively 
the  patient  tries  to  use  the  healthy  limb  and  not  the  unhealthy  one.  This 
is  one  of  the  causes  of  limping.  When  tenderness  can  actually  be  located, 
then  locomotion  is  also  limited.  When  this  exists,  difficulty  in  abduction 
and  adduction  a))])ears. 

When  examining  by  grasping  the  affected   limb  with   one  hand   and 


CONGEJMITAl.    DISLOCATIOX    OF    THE    HIP. 


899 


supjiorting  the  smnll  (if  tlic  l)ack  with  the  second  hand,  a  distinct  resistance 
ol  the  muscles  can  he  felt.  ... 

TUBEIICI-I.OCS    COXITIS    (DOHIiLE). 

C.  M.,  10  years  old,  girl.  Duration  of  disease,  in  left  hip  six  years,  and 
right  hip  five  years.  No  history  of  exantheniatoiis  diseases.  Treated  at  the  Post- 
graduate for  seven  months  in  orthopanlic  ward.  An  era.sion  of  disease  in  left  hip 
at  this  time. 

E.ramindtinii. — Pight  hip  flexed  to  90°,  left  hip  flexed  to  about  95°.  Right  hip 
in  adduction  10°,  distinct  spasm  of  the  adductor  muscles.  Left  hip  in  adduction  35°, 
slight  spasm  of  the  adductor  muscles.  Motion  in  right  hip  10°,  in  left  hip  20°. 
Right  great  trochanter  two  inches  above  Nelaton's  line.  Apparently  no  abscesses. 
Left  trochanter  almost  denuded  by  crasion,  only  slightly  above  Xelaton's  lino. 
Many  abscess  scars,  all  healed. 

Tiruiiiidit. — ^lodified  Gant  on  right  side,  forcible  correction  of  tlie  left  side, 
with  tenotomies. 


Fig.  297. — Tuberculous  Coxitis — Front 
View. 


Fig.  298.— Tubcrculou.s  Coxitis— Side 
View. 


COXGEXITAL  DlSLOCATIOX  OF  THE  HiP. 

This  is  the  most  frequent  form  and  tlie  most  important  of  the  eon- 
genital  dislocations. 

Etiology. —  Faulty  development  of  tlie  aeetahiiluin  and  i\\o  head  of 
the  femur  combined  with  laxity  of  the  capsnle  and  possibly  pressure  upon 
the  flexed  thigh  are  supposed  to  ])e  the  causes  of  this  condition.  The  dis- 
placement is  usually  u])on  the  dorsnm,  although  it  nuiy  take  place  forward 
or  upward.  It  is  most  fre(pu'iit  in  females.  Whitman  states  that  So  jier 
cent,  occur  in   I'enudcs.     It  is  usiiallv  seen  unilateial.     I    have  seen   many 


Illustrations    Figs.    297    and   29S    arc    furnish;-d    thrt)ugli    the   courtesy    of    Dr. 
Dexter  Ashley. 


UOO 


DISEASES    OF    THE    SPTXE    AND    JOINTS. 


cases  bilateral.     Sometimes  a  peculiar  family  predisposition  seems  to  exist, 
as  several  children  in  the  same  family  have  tliis  deformity. 

Symptoms. — ['nihilcml  PislDcatinii :  The  cliild  limps  when  it  bciiins 
to  walk.  'J'he  abdomen  is  very  prominent.  There  is  an  abnormal  lordosis. 
The  buttocks  appear  enlaro-ed.  The  thighs  are  usually  separated  and  there 
is  an  increased  breadth  of  pelvis.  Shortening  is  difficult  to  detect  in  the 
l)eo"inning  of  the  disease,  but  if  the  child  grows  older  and  the  condition 


i 


Fig.   299. — Congenital   Hip   Dislocation.     Cases  occurred  in   the   practice  of 
Dr.  Dexter  Ashley. 


has  been  neglected,  then  a  shortening  of  several  inches  may  sometimes  be 
detected.     Such  children  are  easily  fatigued. 

Bilateral  Dislocation. — The  pelvis  is  broadened  and  the  thighs  are  far 
apart  when  the  patient  stands  or  walks.  The  limp  is  exaggerated  and  the 
child  waddles.     The  lordosis  is  very  marked. 

Treatment.  —  Eeplacement  l)y  traction  by  extreme  abduction  and 
flexion  with  ])rolonged  fixation  in  the  attitude  of  extreme  abduction  known 
as  the  Lorenz  treatment,  is  frequently  successful.  In  some  cases  the 
above  treatment  is  nnsuccessful  and  a  radical  operation  must  then  be 
performed. 


PLATE  XXIX 


X-ray  of  Congenital   Dislocation   of  Ilip. 


KNEE-JOINT    DISEASE.  gQl 

G.  L.,  male,  9  years  old;  A.  L.,  female,  6  years  old;  H.  L.,  female,  4  years  old. 
Three  out  of  five  children  in  one  family,  of  Irish  parentage.  No  previous  historv 
of  lameness. 

C4.  L.,  double  posterior  dislocation;  muscular;  gieat  telescopic  motion;  rio-ht 
side  has  a  shortening  of  2  '/^  inches,  left  side  2^/4  inches,  as  per  Nelaton's  line;  head 
and  neck  apparently  well  developed;  thighs  Hexed  adductetl  and  rotated  inward; 
marked  lordosis;  walking  ungainly  and  laborious;  limited  motion  in  abduction 
and  extension;  feet  inclined  to  be  Hat;  can  stand  in  almost  normal  position  except 
lordosis.  Skiagrapli  reveals  very  well-developed  neck  on  each  side,  the  right  inclined 
to  coxa  varus;  head  on  each  side  inclined  to  be  conical;  acetabula  rather  shallow, 
but  well  formed  otherwise.  Advised  no  operation  a.s  the  child  was  too  old,  and  the 
circumstances  of  the  family  would  not  admit  of  good  after-treatment. 

A.  L.,  right  posterior  dislocation;  distinct  limp;  limb  carried  slightly  in  ad- 
duction; shortening  1  V2  inches;  neck  short  and  straight,  or  co.xa  valgus.  Skiagi-aph 
verifies  above  observations,  and  shows  an  apparently  poorly  formed  acetabulum,  witii 
considerable  thickening.  Preternatural  mobility  in  all  directions  except  abduction. 
Operation  advised  and  performed.      Transposition  secured. 

H.  L.,  4  years  old;  posterior  dislocation;  V4  inch  shortening;  limp  well 
marked;  neck  and  head  rather  short  but  of  normal  angle;  preternatiual  uiobility  in 
all  directions  except  abduction.  Skiagraph  reveals  short  head  and  neck,  apparently 
well  formed  acetabulum.  Operation  performed.  \'ery  good  result,  but  might  have 
been  improved  upon  it  child  had  been  brought  in  for  after-troatment. 

Knek-joint  Disease. 

This  is  a  chronic  tiibereiiloiiii  iiiflaiiiination  due  to  an  osteitis  of  the 
femur  or  tibia.    It  may  begin  as  a  synovitis  similar  to  hip-joint  disease. 

Etiology. — Traumatism  is  usual'y  the  exciting  factor,  as  in  hip-joint 
disease. 

Pathology. — The  pathological  lesions  are  those  of  tuberculosis.  The 
tubercle  bacillus  is  usually  found,  although  it  may  be  absent.  The  lesions 
spread  and  sometimes  cause  complete  destruction  of  the  joint.  A  char- 
acteristic swelling  noted  in  tubercidous  knee-joint  is  caused  by  an  infiltra- 
tion of  the  soft  parts  with  a  gelat'nous  substance  which  must  be  attributed 
to  a  tuberculous  ])n)C('ss. 

Symptoms.- — Children  old  enough  to  complain  will  describe  p:tin  when 
moving  the  joint.  A  limp  is  noticed  when  walking.  A  swelling  of  llic 
joint  gradually  ai)])ears.  The  knee  assumes  a  flexed  a|)pearance  which  is 
quite  ty])ical  of  this  condition.  As  a  resull  of  the  swelling  in  the  joint, 
motion  is  limited,  and  the  ])ain  at  times  is  very  severe.  Fever  may  or  nuiy 
not  be  present.  In  a  case  seen  l)y  me  recently,  although  a  large  ([uantity 
of  pus  was  present,  no  fever  could  he  detected.  This  condition  was  one  ot 
the  usual  "cold  abscess  type."' 

Diagnosis. — 'I'liis  depends  on  the  limitation  id'  motion,  on  the  swcdl- 
ing,  and  on  the  ])ain.  It  does  r.ot  I'esemble  I'heumatism  owing  to  tin*  atl'ec- 
tion  being  limited  to  one  joint.  Tn  rheumatism  there  is  fever,  at  times 
very  high  f(>ver.  iuHanunation.  swelling,  and  a  sudden  onset  of  symj)toms. 
Just  the  reverse  condition  is  found  in  knee-joint  disease. 


902  DISEASES    OF    THE    SPIXE    A.ND    JOINTS. 

Progpiosis. — The  prognosis  as  a  rule  is  good.  Fully  DO  per  cent,  of 
cases  recover,  according  to  Mooro.  \Mun.  however,  cases  are  neglected, 
ankylosis  of  the  knee-joint  results. 

Treatment. — Kest  in  bed,  assisted  b}-  proper  hygiene  and  a  good  su})- 
porting  diet,  constitute  the  general  line  of  treatment  to  be  pursued  by  thv 
general  practitioner.  Tlie  deformity  re(juires  careful  orthopaedic  treat- 
ment. A  ease  of  this  kind  usually  recpiires  a  knee-splint  or  a  plaster  cast. 
It  is  self-understood  that  only  one  competent  to  do  this  should  guide  the 
treatment.  For  details  regarding  the  api^lication  of  knee-splints,  etc.,  the 
reader  is  referred  to  works  on  orthopaedic  surgery. 

Diseases  of  the  Ankle-joint  and  Tarsus. 

Tubercular  disease  frequently  affects  the  ankle  and  tarsus.  The  same 
pathological  manifestations  described  in  hip  and  knee-joint  diseases  are 
found  here. 

Symptoms. — As  a  rule  a  limp  will  be  noticed.  Associated  with  this 
there  is  swelling  of  the  joint,  limitation  of  motion,  and  in  some  cases  fever; 
in  other  cases,  atropliy  of  the  muscles  of  the  leg.  The  superficial  veins  are 
usually  enlarged. 

Diagnosis.— The  slow  onset  of  the  symptoms  associated-  with  swelling 
and  the  limjj  on  walking  will  usually  aid  in  establishing  the  diagnosis. 
It  is  important  to  exclude  rheumatism  by  carefully  examining  other  joints 
of  the  body.  The  diagnosis  rests  u})on  the  disease  being  limited  to  one 
joint  in  addition  to  the  symptoms  above  described. 

Prognosis. — The  })rognosis  is  usually  good.  Cases  usually  recover 
under  proper  management  in  six  to  nine  months. 

Treatment. — The  same  treatment  deseribed  in  the  article  on  knee- 
joint  disease  applies  here.  The  parts  should  be  given  absolute  rest.  This 
can  be  secured  by  the  use  of  plaster  of  Paris  casts.  The  rest  of  the  treat- 
ment is  restorative. 

WitlST-JOINT   AND    ElBOW-JOINT    DISEASE. 

'J'his  condition  is  rarely  met  with  in  children.  When,  however,  tuber- 
culous manifestations  exist  the  sym])toms  are  the  same  as  described  in 
other  tubercular  joints. 

Treatment  consists  in  securing  rest  and  ininiobility  of  the  parts  with 
the  aid  of  plaster  casts.  Pus,  when  ])resent,  re([uir('s  surgical  relief.  The 
onteonie  of  these  cases  is  as  a  rnle  good. 

.Tosepli  S..  10  yciirs  old.  lias  been  under  tlio  troatmoiit  of  Dr.  Doxtcr  Asliloy.  to 
whom  T  am  indebted  for  the  illustration.  The  ehild  wa.s  in  an  extremely  anoemic 
condition,  heart  and  lungS  nomial,  no  evidence  of  tuberculosis.  Family  history  good. 
Local  evidence  of  tuberculosis  involving  the  elhow-joint,  so-called  bone  tuberculosis. 


ACUTE    ARTHRITIS. 


903 


The  boy  was  able  to  run  about,  and  excepting  this  arm  seemed  to  be  in  a  fair  physi.eal 
condition.  A  comparison  of  the  healthy  elbow-joint  with  the  diseased  joint  is  quite 
interesting.  Dr.  Ashley's  treatment  consisted  in  strict  aseptic  dressings,  ti^ht 
bandaging,  a  bandage  to  support  the  return  circulation  and  general  restorative  treat 
ment. 


Fig.  WO. — Tubercular  Elbow- joint. 


Acute  Arthritis  (Ixfectious  Osteitis:    Acute  Pueulext  Synovitis: 
Acute  Epiphysitis:    Acute  Osteomyelitis). 

This  is  an  acuto  inflammatorv  condition  involving  a  joint.  Tt  i^^ 
always  suppurative  from  the  l)e,i,nnnin«r ;  it  is  therefore  a  form  of  pya'iiiia. 
]t  is  an  inf(K-t"on  oriMJnatinu-  at  the  hone  in  the  miMlnllary  canal  or  in  th'' 
joint. 

Etiology. — 'I'his  condition  may  follow  the  aciilc  inreclions  diseases, 
especially  those  which  show  a  tendency  lo  sii])purative  jtroccsses.  It  most 
frequently  follows  measles,  scarlet  fever,  and  empyema. 

There  seems  to  he  no  reason  jo  Ix'ljeve  Ihat  this  disease  ow(>s  its  exisi- 
ence  to  sypliilis,  tuherculosis.  or  scrofidosis.  Some  authors  slat(^  Ihal  a 
In'story  of  traumatism  has  preceded  ihis  infectious  disease. 

Bacteriology. — Cullures  taken  of  the  purulent  discharge  usually  sIiom 


904 


DISEASES    OF    THE    SPINE    AKD    JOINTS. 


the  presence  of  the  streptococcus  pyogenes  or  the  staiDhylococcus.  The 
point  of  entrance  for  the  pathogenic  bacteria  may  be  either  the  skin,  if 
abraded,  the  umbilicus,  or  the  tonsil.  In  this  manner  the  bacteria  gain 
entrance  to  the  circulation. 

Symptoms. — Distinct  swelling  of  the  joint  can  be  made  out,  although 
the  intlannnatory  condition  is  deep-seated.  The  joint  is  red  and  inflamed 
and  has  a  glazed  appearance.  Fluctuation  can  be  felt  if  properly  palpated. 
The  usual  symptoms  of  inflammation,  such  as  high  fever  and  chills  or 
rigors,  are  present. 

The  joints  most  usually  affected  are  best  judged  by  studying  Town- 
send's  collection  of  cases : — 

Hip    38  cases 

Knee  27  cases 

Shoulder   12  caseSK 

Wrist    5  cases 

Elbow  4  cases 

Ankle    4  cases 

Fingers    2  cases 

Toes    1  case 

Sterno  clavicula 1  case 

Diagnosis  and  Differential  Diagnosis. —  The  diagnosis  is  easily  made  if 
we  remember  the  rapidity  with  which  this  condition  develops.  It  may 
resemble  rheumatism,  but  the  acute  onset  with  the  fever  and  the  suppura- 
tion makes  it  easy  to  exclude  rheumatism.  Syphilis  may  resemble  arthritis, 
but  the  fever  and  suppuration  are  never  present  in  syphilis. 

Progpiosis. — If  the  disease  extends  rapidly  death  may  occur  in  a  few 
days.  The  outcome  of  the  case  depends  on  recognizing  the  disease  in  its 
early  stages,  and  on  the  rapidity  with  which  the  suppurative  condition  is 
relieved. 

Treatment. — The  treatment  is  surgical.  With  aseptic  care  and  atten- 
tion to  surgical  detail,  pus  should  be  evacuated  and  the  joint  properly 
immobilized.  To  prevent  deformity  fixation  of  the  joint  should  be  remem- 
Ijcred.  licstorative  treatment  should  consist  in  giving  arsenic,  maltine  Avith 
hvpophopphites,  in  addition  to  concentrated  food  and  general  hygienic  care. 
The  surgical  treatment  should  be  given  into  the  hands  of  a  surgeon. 


PART  XIT. 

MISCELLANEOUS. 

CHAPTEIi  I. 
DIETARY. 

Bevera(;e8. 

Albumin  Water. — Stir  the  whites  of  2  eggs  into  i  •>  pint  of  ice-water, 
without  beating;  add  enough  salt  or  sugar  to  make  it  palatable.  Such  a 
mixture  is  one  of  the  best  foods  we  have  for  substitute  feeding  an  infant 
Avith  digestive  disturbances  when  we  wish  to  tem])orarily  stop  all  milk-food. 

Almond-milk. — Take  two  ounces  of  sweet  almonds,  scald  them  with  boil- 
ing water ;  alter  a  few  moments  express  them  from  the  hulls  ;  then  pour  the 
hot  water  away.  Put  the  blanched  almonds  into  a  mortar  and  pound  them 
thoroughly,  and  add  eithc-r  2  ounces  of  milk  or  2  ounces  of  plain  water. 
After  this  is  thoroughly  mixed,  it  is  to  be  strained  through  cheese-cloth, 
and  the  strained  liquid  will  be  the  almond-milk. 

Arrowroot  Water. — Add  2  tablespoonfuls  of  arrowroot  to  1  pint  of 
water;  allow  it  to  simmer  for  half  an  hour,  stirring  it  constantly. 

Barley  Water. — Take  a  tablcspoonful  of  pearl  barley,^  grind  it  in  a 
coffee-grinder,  or  pound  it  in  an  ordinary  mortar;  add  1  quart  of  cold 
water,  and  allow  it  to  simmer  slowly  for  about  an  hour.  Strain  and  add 
enough  water  to  make  1  quart. 

Beef  Juice. — Expressed  beef  juice  is  obtained  by  slightly  broiling  a 
piece  of  lean  l>eef  and  expressing  the  juice  with  a  lemon-squeezer.  One 
])ound  of  steak  yields  2  or  3  ounces  of  juice.  This  is  flavored  with 
salt  and  given  cold  or  warm.  Do  not  heat  enough  to  coagulate  the  albumin. 
This  is  very  nutritious  and  usually  well  taken.  It  may  be  given  at  the 
rate  of  a  tablcspoonful  three  times  a  day. 

Cocoa. — For  each  large  cup  take  a  teaspooni'ul  of  cocoa  and  a  tea- 
spoonful  of  sugar;  mix  to  a  paste  with  a  little  boiling  water  or  milk;  add 
balance  of  milk  or  milk  and  water,  as  richness  is  desired.  T^et  it  l)oil  a 
iniiiutc.  as  boiling  improves  it. 

Chocolate  (Unsweetened). — ^For  each  break fastcup  take  1  division, 
break  in  small  pieces,  and  allow  to  melt;    add  milk  or  milk  and  water,  as 


1  Prcparcfl  hailcy   Hour  cini  Ik'  inocurcd   in  [(oiiiiil  boxes  from  llic  HimIiIi    l-ood 
roiiipaiiy  of  New    ^'o^k   ('ity. 

(*)or,) 


906  MISCELLANEOUS. 

richness  is  desired.  Stir  constantly.  Bring  to  a  boiling  point  and  set 
aside  to  simmer.     Sugar  to  taste. 

Eggnog. — Heat  some  milk  to  a  temperature  of  150°  F.,  but  do  not 
allow  the  milk-  to  boil.  When  cold,  beat  up  a  fresh  egg  with  a  fork  in  a  tum- 
bler with  some  sugar;  beat  to  a  froth,  add  a  dessertspoonful  of  brandy,  and 
till  uj)  tunii)ler  with  the  warm  milk. 

Oatmeal  Water. — Take  a  tablespoonful  of  ordinary  oatmeal,  and  add 
1  pint  of  water,  .\llow  it  to  simmer  slowly  for  one  hour  and  strain.  Add 
enough  water  to  make  1  pint.  The  same  directions  apply  to  making  a 
household  mixture  of  farina-water,  and  sago-water,  using  the  same  propor- 
tions as  above. 

Rice  Water. — One  ounce  of  well-washed  C'arolina  rice.  Macerate  for 
three  hours  at  a  geutle  heat  in  a  quart  of  water,  and  then  boil  slowly  for 
an  hour  and  strain.  It  may  be  sweetened  and  Havored  with  a  little  lemon- 
l)eel.  Useful  in  diarrhoea,  etc.,  when  the  flavoring  is  l)est  dispensed  with, 
and  a  little  old  cognac  added. 

Yolk  of  Egg  Lemonade. — Take  the  beaten  yolk  of  1  egg  and  add  to 
it  the  juice  ofy^  Idion-  I^^'t  stand  five  minutes,  thus  drawing  off  the  raw 
taste  of  the  yolk  of  egg.    Add  1  teas})oonful  of  sugar  and  8  ounces  of  water. 

White  of  Egg  Orangeade. — Take  the  juice  of  1  orange  and  1  ounce 
of  water,  insert  an  egg  whisk,  and  when  the  orangeade  is  in  full  agitation, 
add  slowly  the  white  of  ogg.  Continue  the  whisking  for  two  or  three  min- 
utes more.     Add  14  teaspoonful  of  sugar. 

White  of  Egg  Lemonade. — Leftwich^  advises  the  following  for  a  nutri- 
tive drink  for  febrile  and  wasting  diseases: — 

IJ  Lemons    2 

Wliite  of  eggs 2 

Boiling   water 1  pint 

Loaf  sugar  to  taste. 

The  lemon  must  be  ])eeled  twice — the  yellow  rind  alone  being  utilized 
— wliile  the  white  layer  is  rejected. 

Place  the  sliced  lemon  and  the  yellow  ])eel  in  a  quart  jug  with  2  lumps 
of  sugar.  l*our  uj)on  them  the  boiling  water  and  stir  occasionally.  When 
cooled  to  the  ordinary  temperature,  strain  oil'  the  lemons. 

Now  insert  an  vgg  whisk,  and  when  the  lemonade  is  in  full  agitation 
add  slowly  the  white  of  egg.  Continue  the  whisking  for  two  or  three 
minutes  more.     While  still  hot,  strain  through  muslin.     Serve  when  cold. 

The  white  of  egg  will  be  found  to  impart  a  blandness  which  makes 
the  addition  of  sugar  ahnost  unnecessary. 

Tin's  drink  is  very  useful  in  the  febrile  diseases  of  children.  It  may 
he  given  simply  as  a   lemonade,  without  mentioning  the  eggs,   and  will 

'  Edinburgh  Medical  Jonrnal. 


DIETARY. 


907 


thus  be  readily  taken  by  the  chiklren  and  difficult  patients.  It  also  pos- 
sesses antiscorbutic  properties,  which  replace  those  lost  from  milk  by  boil- 
ing and  sterilizing. 

Soups  and  Broths. 

Chicken  Broth. — Cut  up  a  small  chicken,  put  bones  and  all,  with  a 
sprig  of  parsley,  salt,  1  tablespoonful  of  rice,  and  a  crust  of  bread,  in  a 
quart  of  water  and  boil  for  one  hour,  skimming  it  from  time  to  time. 
Strain  through  a  coarse  colander. 

Keller's  Malt  Soup. — Take  of  wlieat-flour  50.0  (about  2  ounces).  To 
this  add  11  ounces  of  milk.  Soak  the  wheat-Hour  thorougbly,  and  rub  it 
through  a  sieve  or  strainer. 

Put  into  a  second  dish  50  ounces  of  water,  to  which  add  3  ounces  of 
malt  extract;  dissolve  the  above  at  a  temperature  of  about  120°  F.,  and 
then  add  lU  cubic  centimeters  (about  2  V-  drachms)  of  11  per  cent,  potas- 
sium bicarbonate  solution.  Finally  mix  all  of  the  above  ingredients,  and 
ijoil. 

This  gives  a  food  containing: — ■ 

Albuminoids   2.0  per  cent. 

Fat 1.2  per  cent. 

Carbohydrates    12.1  per  cent. 

There  are  in  th;s  mixtuic: 

Vegetable  proteids    0.9  per  cent. 

The  wheat-Hour  is  necessary,  as  otherwise  the  malt  soup  would  have 
a  diarrheal  tendency,  'i'he  alkali  is  added  to  neutralize  the  large  amount 
of  acid  generated  in  sick  children.  Biedert  em})hasi/,es  the  importance  of 
giving  fat,  rather  than  reducing  its  ([uantity.  in  ])oorly  nourished  children. 
and  cites  the  assimihd)ility  of  his  cream-mixture  or  of  breast-milk  in  under- 
fed children  as  proof  of  his  assertions.  The  author  has  used  this  nuilt 
soup  most  successfully  in  the  treatment  of  atlirepsia  (marasmus)  cases  in 
which  tlu>  children  were  simply  starved. 

Mutton  Soup. — Cut  up  fine  2  ])ounds  of  h'an  mutton,  without  I'at  or 
skin.  Add  1  tabh-spoonful  oi'  barley,  1  (juart  of  cold  water,  and  a  teaspoon- 
ful  of  salt.  Let  it  boil  slowly  for  two  hours,  if  I'ice  is  used  in  place  of 
barley,  soak  the  rice  in  water  over  night,  if  it  is  to  l)e  boiled  in  the  morning. 

Oyster  Broth. --Cut  into  snuill  pieces  1  pint  of  small  oysters;  j)ut  them 
into  V'  P'"^^  <*'  <'"1'^  water,  and  let  them  simmei-  gently  for  ten  minutes 
over  a  slow  fin\     Skim,  strain,  and  add  salt. 

White  Celery  Soup. — Take  \/.,  pint  of  strong  beei'-tea  :  add  an  e«pi-il 
quantity  of  boiled  milk,  slightly  and  evenly  thickeiu'd  with  ilour.  Flavor 
with  celerv  seeds  or  ])ieces  of  celery,  wliich  are  to  be  strained  oul  before 
servinir.     Salt  to  taste. 


CJ08  miscella:^  eo  u  s. 

PCDDINGS  AND   DESSERTS. 

Calf's-foot  Jelly. — Thoroughly  clean  2  feet  of  a  calf,  cut  into  pieces, 
and  stew  in  2  quarts  of  water  until  reduced  to  1  quart;  when  cold,  take  off 
the  fat  and  se])arate  the  jelly  from  the  sediment.  Then  put  the  jelly  into 
a  saucepan,  with  the  sliells  and  whites  of  4  eggs  well  mixed  together;  boil 
for  a  quarter  of  an  hour,  cover  it,  and  let  it  stand  for  a  short  time,  and 
strain  while  hot  through  a  flannel  bag  into  a  mould.     Flavor  with  lemon. 

Baked  Apples. — Core  and  ])are  2  tart  apples;  fill  the  core-holes  with 
sugar;  grate  over  the  apples  a  little  nutmeg;  add  a  little  water  to  baking- 
l)an  and  ])ut  in  oven  and  bake  until  the  apples  are  soft.  Serve  with  rich 
milk  or  cream.     Sprinkle  with  icing  sugar,  if  not  sweet  enough. 

Cornstarch  Pudding. — Take  1  pint  of  milk,  and  mix  with  it  2  table- 
spoonfuls  of  cornstarch;  flavor  to  taste;  then  boil  the  whole  eight  minutes; 
allow  it  to  cool  in  a  mould. 

Custard  Pudding. — Break  1  egg  into  a  teacup,  and  mix  thoroughly 
with  sugar  to  taste;  then  add  milk  to  nearly  fill  the  cup,  mix  again,  anil 
tie  over  the  cup  a  small  piece  of  linen ;  place  the  cup  in  a  shallow  saucepan 
half-full  of  water  and  boil  for  ten  minutes. 

If  it  is  desired  to  make  a  light  batter  pudding,  a  teaspoonful  of  flour 
should  be  mixed  in  with  the  milk  before  tying  up  the  cup. 

Infant's  Gelatine  Food. — Abont  1  teaspoonful  of  gelatine  should  be 
dissolved  l)y  boiling  in  V-  pi^t  of  water.  Toward  the  end  of  the  boiling 
1  gill  of  cows'  milk  and  1  teaspoonful  of  arrowroot  (made  into  a  paste  Avith 
cold  water)  are  to  be  stirred  into  the  solution,  and  1  to  2  tablespoonfuls  of 
cream  added  just  at  the  termination  of  the  cooking.  It  is  then  to  be  mod- 
erately sweetened  with  white  sugar,  when  it  is  ready  for  use.  The  whole 
preparation  should  occupy  about  fifteen  minutes. 

Junket  of  Milk  and  Egg. — Beat  1  egg  to  a  froth  and  sweeten  with  2 
teaspoonfuls  of  white  sugar.  Add  this  to  \/„  pint  of  warm  milk;  then 
add  1  teas])oonful  of  essence  of  pepsin  (Fairchild)  ;  let  it  stand  till  it  is 
curdled.     The  a])ove  is  useful  in  typhoid  and  similar  wasting  diseases. 

Jelly  Sugar  (Price). — This  is  a  combi-nation  of  refined  gelatine  sugar 
and  lemon  acid.  It  is  very  well  adapted  for  children  over  2  years  of  age. 
It  can  be  made  in  a  moment  by  adding  hot  water. 

It  is  very  nutritious  and  easily  assimilated,  and  can  be  bought  with 
any  desired  flavor. 

Predigested  Eggs. — Break  a  fresh  egg.  After  thoroughly  stirring  add 
to  it  2  grains  of  caroid  powder  and  stir  tlioroughly.  The  yolk  is  at  once 
changed  into  a  limpid  liquid  and  soon,  though  not  so  quickly,  the  albumin 
is  completely  dissolved.     This  is  done  at  a  temperature  of  70°  to  80°  F. 

Predigested  Rice.— Take  V^  pound  of  rice,  add  water,  and  boil  until 
soft.     Break  grains  by  passing  tli rough  a  colander.     Take,  of  bana-diatase, 


DIETARY.  909 

8  grains,^  and  dissolve  it  in  1  ounce  of  water  and  add  to  the  rice,  which  mut-t 
be  kept  warm,  but  not  hot.  Let  stand  for  two  hours  at  a  teni2)erature  of 
105°  F.  \A'heu  rice  is  thoroughly  softened,  season  with  salt,  sparingly. 
Add  a  little  cream  if  desired.     Serve  hot  or  cold. 

Rice  Pudding. — Boil  a  teacupful  of  rice,  drain  off  the  water;  add  a 
tablespoonful  of  cold  butter.  Mix  with  it  a  cupfvd  of  sugar,  a  quarter  tea- 
spoonful  of  ground  nutmeg,  and  a  quarter  teaspoonful  of  cinnamon.  Beat 
up  4  eggs  very  light,  whites  and  yolks  separately;  add  them  to  the  rice; 
stir  in  a  quart  of  sweet  milk  gradually.  Butter  a  pudding  dish,  turn  in 
the  mixture,  and  bake  one  hour  in  a  moderate  oven. 

If  you  have  cold  cooked  rice,  first  soak  it  in  the  milk,  and  proceed 
as  above. 

Sago  Pudding. — Same  as  above  recipe,  sago  being  substituted  for  rice. 

Soft  Custard. — Take  of  cornstarch  2  tablespoonfuls  to  1  quart  of  milk; 
mix  the  cornstarch  with  a  small  quantity  of  the  milk,  and  flavor;  beat  u\) 
2  eggs.  Heat  the  remainder  of  the  milk  to  near  boiling;  then  add  the 
mixed  cornstarch,  the  eggs,  4  tablespoonfuls  of  sugar,  a  little  butter,  and 
salt.     Boil  the  custard  two  minutes,  stirring  briskly. 

Tapioca  Cream. — Take  1  ])int  of  milk,  2  tablespoonfuls  of  tapioca,  2 
tablespoonfuls  of  sugar,  1  saltspoonful  of  salt,  and  2  eggs.  Wash  tlu^ 
tapioca.  Add  enough  water  to  cover  it,  and  let  it  stand  in  a  warm  place 
until  the  tapioca  has  absorl)e(l  the  water.  Then  add  tln'  m'lk  and  cook  in 
a  double  boiler,  stirring  often  until  the  tapioca  is  clear  and  transparent. 
r>eat  the  yolks  of  the  eggs.  Add  the  sugar  and  salt  and  the  hot  milk. 
Cook  until  it  thickens.  Eemove  from  the  fire.  Add  the  whites  of  the  eggs, 
beaten  stitf.     When   cold,  add   1  teaspoonful  of  vanilla. 

Modified  Cows'  Milk. 

Humanized  Milk. — A  pint  of  milk  is  set  aside  until  the  CT-eam  rises, 
and  this  cream  is  skimmed  off'  and  kept.  To  the  milk  remaining  is 
added  enoi^gh  rennet  to  curdle  it.  The  whey  is  strained  off  tlie  curd  and 
added,  with  the  previously  separated  cream,  to  a  pint  of  fresh  cows'  milk. 
This  is  known  as  humanized  milk.  In  some  infants  it  will  be  well  horiu' 
during  tlie  first  three  months,  and  to  tliis  can  he  added  farinaceous  liquid 
for  dilution   if  r('C(uir('d. 

Pasteurized  Milk. — Tliis  is  really  partially  sterilized  milk,  and  consists 
of  sterilization  at  a  temperature  of  1  10°  V.  instead  of  212°  F.,  this  sterili- 
zation to  be  continued  for  from  twenty  minutes  to  half  an  hour.  Pasteur- 
ized milk  should  only  be  used  during  the  twenty-four  hours  following  this 
process.  A  good  apparatus  for  this  pur])0se  is  Kilmer's  pasteurizing  a]»- 
paratus. 


*  American  Fcniient  Coiiipiuiy. 


910  M1S(  KLLANKOl  S. 

Predigested  or  Peptonized  Milk. — This  is  milk  in  which  the  proleids 
arc  changed  to  peptones,  <ir,  in  other  words,  digested,  hy  the  addition  and 
action  of  })ancreatic  lernient.  'Idiis  process  may  be  stopped  when  partially 
])erl'orined.  giving  a  product  ol"  which  the  taste  is  not  objectionable;  or  it 
may  be  carried  on  to  coiu])lete  j)eptonization,  when  the  product  has  a  very 
bitter,  disagreeable  taste. 

Method. — To  partially  peptonize  milk,  add  to  1  pint  of  fresh  cows' 
milk  and  4  ounces  of  water.  5  grains  of  pancreatic  extract  and  15  grains  of 
bicarbonate  of  soda.  Allow  this  to  stand  at  a  temperature  of  105°  to  115° 
F.  for  five  to  twenty  minutes,  then  bring  to  a  boil  1o  kill  the  ferment,  or 
stand  on  ice  to  prevent  its  further  action.  If  the  milk  is  to  be  used  at  once, 
neither  of  these  latter  is  necessary. 

To  peptonize  the  milk  completely,  allow  the  process  to  continue  for 
one  to  two  hours.  After  this  time  the  addition  of  acid  produces  no  coagu- 
lation. 

In  infant-feeding  it  is  better  to  peptonize  a  modified  than  a  whole 
nulk.  'Pej)tonized  milk  is  frequently  very  useful  in  feeding  an  infant  with 
feeble  digestive  powers;  but  it  is  unwise  to  continue  its  use  over  too  long 
a  period,  as  then  the  infant's  stomach,  being  called  on  to  do  no  work,  be- 
comes enfeebled  from  disuse,  and  gradually  unable  to  perform  its  proper 
function. 

Whey. — By  coagulating  1  pint  of  fresh  (raw)  milk  by  adding  a  tea- 
spoonfui  of  essence  of  pepsin,  and  allowing  this  to  stand,  a  solid  curd  is 
formed  swimming  in  a  liquid  (wdiey).  This  has  the  following  composition: 
Proteids,  0.86  per  cent. ;  fat.  0.32  per  cent. ;  sugar.  4.T9  per  cent. ;  salts, 
0.G5  per  cent. ;  water,  93.3  per  cent. 

This  at  times  makes  a  very  valuable  food  for  infants  in  cases  of  gastric 
or  intestinal  disorder,  where  the  use  of  milk  must  for  a  time  be  interdicted. 
Babies  like  it,  it  is  very  easy  of  digestion,  and  does  not  irritate  the  stomach. 

When  such  Avhey  is  added  to  milk  for  an  infant  under  (5  weeks  take. 
of  whey,  2  parts;  milk,  1  part.  This  can  be  increased  until  equal  parts 
of  milk  and  whey  are  used  for  a  child  several  months  old. 

Preparation  of  Sweet  Whey. — Sweet  whey  is  best  made  l)y  the  follow- 
ing method :  For  each  ])int  of  whey  needed  take  1  (piart  of  raw^  milk 
or  fat-free  milk,  heated  to  37.7°  C.  (100°  F.),  and  add  8  cubic  centimeters 
(2  drachms)  of  the  essence  of  ]K'psiu  or  some  of  the  ])reparations  of  liquid 
rennet.  This  wall  precipitate  the  casein  in  the  form  of  a  curd,  which  is 
tiien  broken  up  with  a  fork  ;  the  fluid  which  remains  is  the  w^hey.  This 
is  strained  through  two  thicknesses  of  boiled  cheese-cloth  and  one  thick- 
ness of  absorbent  cotton  and  slowly  cooled,  to  a  temperature  of  10°  C.  (50° 
F.),  and  kept  on  ice  until  needed.  If  the  whey  is  to  be  mixed  with  cream, 
it  must  first  be  heated  to  65.5°  C.  (150°  F.).  in  order  to  kill  the  rennet 
enzyme.     Whey  mixtures  should  not  be  heated  above  68.3°  C.   (155°  F.) 


DIETARY.  9^1 

if  one  wishes  to  keep  safely  under  the  coagulation-point  of  the  hictalljiiiuiu. 
Add  1  teasjioonful  of  cane-sugar  to  each  pint  of  liquid. 

Miscellaneous. 

Milk  Toast. — Take  1  cupful  of  milk.  '/,  teaspoonful  of  cornstarch,  V2 
teaspoonful  of  butter,  2  slices  of  dry  toast,  1  saltspoonful  of  salt.  Scald 
the  milk.  Add  the  moistened  cornstarch.  ]\Ielt  the  butter  in  a  saucepan; 
when  hot  and  bubbling,  pour  in  the  hot  milk  slowly,  heating  all  the  time 
until  smooth.  Let  it  boil  up  once.  Then  add  the  salt.  Toast  2  slices  of 
bread.  Pour  the  thickened  milk  over  the  slices.  Let  it  stand  a  few 
minutes.     Serve. 

Scraped  Beef. — Scraped  beef  is  prepared  by  scraping  with  a  dull  knife 
some  raw  or  underdone  lean  heef.    Add  salt  and  serve  on  bread  or  biscuit. 

Scrambled  Eggs. — Take  2  eggs,  a  pinch  of  salt,  2  tablespoonfuls  of 
milk,  and  a  small  juece  of  butter.  Beat  the  eggs  lightly,  add  the  salt  and 
jiiilk.  Put  tlie  butter  into  a  saucepan,  when  melted  and  hot,  add  the  eggs. 
Stir  until  of  a  soft  creamy  consistency.     Serve  on  buttered  toast. 

Soft-boiled  Eggs. — Drop  2  eggs  into  enough  l)oiling  water  to  cover 
them.  Let  them  stand  on  the  back  of  stove,  where  the  water  will  keep  hot, 
but  not  boil,  for  eight  minutes.  An  egg  to  be  properly  cooked  should  never 
be  boiled  in  boiling  water,  as  the  white  hardens  unevenly  before  the  yolk  is 
cooked.    The  yolk  and  white  should  be  of  a  jelly-like  consistency. 


CHAPTEE  II. 

THE  ADULTERATION  OF  MILK, 

FoiniALDKlIYDE   IX    MiLK. 

1'iiE  adulteration  of  milk  hy  the  use  of  formaldehyde  is  he- 
coming  more  common  than  is  generally  suspected.  For  a  time  its 
use  was  a  "trade  secret,"  hut  it  has  heen  so  thoroughly  advertised  that  every 
obscure  individual  who  has  a  milk  route  is  now  familiar  with  the  preserva- 
tive qualities  of  formaldehyde,  hi  our  large  cities  the  health  officers  are 
on  the  watch,  and  hence  in  these  its  use  is  being  curtailed,  but  in  the 
smaller  towns  and  villages  the  people  have  not  this  protection.  It  would 
be  well,  therefore,  for  physicians  to  guard  against  this  and  keep  it  in 
mind  when  mysterious  illness  develops  in  milk-users.  They  should  also 
l)e  prepared  to  make  an  analysis  of  milk  at  any  time  as  to  its  freedom  from 
the  drug.  This  is  a  simple  procedure,  and  yet  one  that  requires  consider- 
able technical  skill  in  the  use  of  some  of  the  tests.  The  Lancet-Clinic  gives 
the  various  methods  for  testing  formaldehyde  as  laid  down  by  Herman 
Harms,  some  of  which  are  quite  simple: — 

Rimini  Test. —  (A):  Phenyl-hydrazine  muriate.  0.5  gram;  distilled 
water,  100  cubic  centimeters;  dissolve.  (B)  :  Sodium  nitroprusside,  0.5 
gram;  distilled  water,  30  cubic  centimeters;  dissolve.  (C)  Soda,  U.S. P., 
15  grams;  distilled  water,  60  cubic  centimeters;  dissolve.  To  15  cubic 
centimeters  of  the  suspected  milk  in  a  test-tube  add  10  drops  of  A,  mix 
and  add  3  drops  of  B;  mix  and  let  5  drops  of  C  run  in  slowly  on  the  side 
of  the  test-tube.  In  the  presence  of  formaldehyde  a  blue  color  is  instantly 
produced,  changing,  on  standing,  to  red.  On  adding  to  the  mixture  of 
milk  and  solution  ,1.2  drops  of  feri'ie  chloride  solution,  and  then  about  2 
cubic  centimeters  of  concentrated  hydrochloric  acid,  a  red  color  is  pro- 
duced, which  later  changes  to  orange-yellow.  In  sour  milk  the  above-men- 
tioned blue  is  supplanted  by  green.  The  Kimini  test  is  easily  applied,  and 
readily  detects  formaldehyde  when  present  to  the  extent  even  of  1  part 
in  25,000  or  30,000. 

Phloroglucin  Test.— Dissolve  1  gi'am  of  phloroglucin  in  100  cubic 
centimeters  of  distilled  water.  Put  10  cubic  centimeters  of  the  suspected 
milk  in  a  test-tube  and  add  5  cubic  centimeters  of  the  phloroglucin  solu- 
tion; shake  and  add  1  cubic  centimeter  of  solution  of  potassa  (U.S.P.). 
If  formaldehyde  is  present,  a  red  color  is  developed  at  once,  fading  usu- 
(912) 


THE    ADULTERATION    OF    MILK.  91 3 

ally,  within  five  or  ten  niiuutes ;  hence  the  color  must  be  observed  at  once. 
One  part  in  20,000  gives  a  decided  reaction. 

Hehner's  Test. — To  15  cubic  centimeters  of  concentrated  sulphuric 
acid  in  a  test-tube  add  1  or  2  drops  of  ferric  chloride  test  solution  (U.S. P.) 
and  mix.  Then  pour  upon  this,  in  such  manner  as  not  to  mix  the  layers, 
the  suspected  milk.  A  violet  color  indicates  the  presence  of  formaldehyde. 
In  the  case  of  cream  dilute  the  cream  with  an  equal  volume  of  water,  and 
then  apply  the  test  as  above  described.  The  violet  color  is  sometimes  pro- 
duced at  once,  but  oftener  not  for  five  or  ten  minutes,  and  sometimes  not 
for  an  hour  or  so,  depending  on  the  amount  of  formaldehyde  present.  By 
this  test  1  part    in  10,000  or  15,000  is  readily  detected. 

Liebermann  Phenol  Test. — In  the  presence  of  small  traces  of  for- 
maklehyde,  distill  off  from  the  milk  a  few  cubic  centiiucters,  and  add  to 
tliis  1  drop  of  very  dilute  aqueous  phenol  solution.  Then  pour  this  mix- 
ture slowly  upon  concentrated  sulphuric  acid  in  a  test  tube  solution  so  as 
to  form  a  layer.  A  bright  crimson  color  appears  at  the  zone  of  contact. 
This  is  easily  seen  in  as  little  as  1  part  in  300,000,  and  in  greater  propor- 
tion in  1  to  100,000.  There  is  a  milky  zone  above  the  rod  color,  and,  if 
more  concentrated,  there  will  be  a  whitish  or  pinkish  precipitate.  Some- 
times the  zone  M'ili  appear  in  about  one  hour,  one-tenth  of  an  inch  below 
tlie  line  of  contact. 

Hydrochloric  Test. — Fifteen  or  20  cubic  centimeters  of  suspected  milk, 
together  with  2  or  3  cubic  centimeters  of  strong  hydrochloric  acid,  are 
boiled  for  a  few  minutes  in  a  test-tube.  A  red  coloration  indicates  for- 
maldehyde. Other  tests  are  known,  but  they  are  more  complicated  and 
require  apparatus  or  reagents  not  kept  by  the  average  pharmacist.  The 
above  tests  are  all  simple  in  their  application  and  afford  a  ready  means  of 
detecting  formaldehyde  in  milk  and  cream. 

Remarks  on  the  Foregoing  Tests. — The  Eimini  test  is  highly  recom- 
mendable.  The  reaction  in  sweet  milk  a])pears  rapidly  and  with  certainty. 
Hehner's  test,  as  well  as  the  phloroglucin  and  phenol  tests,  are  very  reliable 
and  are  all  extremely  sensitive.  The  hydrochloric  acid  test  is  very  simple, 
but  is  not  to  be  depended  on;  it  may  show  formaldehyde  in  most  instances; 
however,  cases  have  come  under  our  observation  when  it  has  utterly  failed 
to  show  the  reaction,  probably  because  of  the  milk  having  undergone  some 
unknown  changes.  The  Liebermann  test  is  simple,  delicate,  and  shows 
formaldehyde  very  readily. 

As  corroborative  evidence,  it  is  well,  after  the  tests  are  finished,  to 
k;t  the  suspected  milk  or  cream  stand  in  a  warm  place  for  tvventy-l'our 
hours.  A  pure  sample  will  invariably  turn  sour  and  separate.  A  sample 
nliich  has  been  "doctored"  with  formaldehyde,  liowever.  will  show,  at  the 
end  of  twenty-four  hours,  but  a  very  slight  separafion,  if  indeed  any  at 
all,  and  will  have  but  a  slight  odor. 


914  MISCELLANEOUS. 

A  ^Nor(l  of  Caution.- — It  is  (losirahlo  tliat  all  tost  solution?  be  freshly 
prepared,  especially  the  iiitroprussitle  of  sodium  solution  in  the  Kiniiui 
test,  and  that  the  suspected  sample  be  as  fresh  as  possible.  Sour  samples 
are  dilficult  to  test,  and  may  yield  variable  results,  because  in  these  for- 
maldehyde has  l)een  oxidized,  and  is  no  longer  present  as  formaldehyde. 
In  carrying  out  the  tests  for  formaldehyde  it  is  advisable  to  work  the  sus- 
])ected  sample  and  the  one  known  to  Ix'  pure  side  by  side.  Finally,  do 
not  expose  your  tests  or  have  your  milk  phieed  where  a  bottle  of  formalde- 
hyde is  being  opened,  for  the  vapor  is  very  penetrating,  and  you  thus  may 
be  easily  led  to  misleading  results.  When  formaldehyde  has  been  found 
to  be  present  by  at  least  three  of  the  aforementioned  tests,  it  may  be  con- 
sidered that  its  presence  has  been  shown. 


CHAPTER  III. 

THE  EXAMINATION  OF  THE  GASTRIC  CONTENTS  IN  CHILDREN.' 

Chemical  Examixatiox.- 

After  the  removed  clivle  is  filtered  it  is  ready  for  the  following 
tests : — 

Hydrochloric  Acid. — Free  hydrochloric  acid  turns  Congo-red  a  deep 
blue  color;  but  as  the  presence  of  large  quantities  of  lactic  and  other  or- 
ganic acids  gives  the  same  reaction,  and  as  the  phloroglucin-vanillin  (Giinz- 
burg's  reagent)  does  not  respond  to  the  organic  acids,  it  is  better  not  to 
depend  upon  the  simpler  Congo-red  test.  One  or  two  drops  of  the  filtered 
stomach-contents  are  placed  on  a  white  porcelain  dish;  the  same  amount 
of  the  reagent  is  added  and  thoroughly  mixed  with  a  glass  rod ;  the  dish 
is  then  gently  warmed  over  the  flame.  The  appearance  of  a  bright  cherry- 
red  color  on  the  edge  of  the  residue  indicates  the  presence  of  free  hydro- 
chloric acid. 

To  10  cubic  centimeters  of  the  filtered  chyle  add  1  drop  of 
phenolphthalein  solution :  to  this  add  drop  by  drop  from  the  burette  a 
decinormal  solution  of  potassium  or  sodium  hydrate  until  after  thoroughly 
stirring,  a  pink  color  persists;  now  read  carefully  the  number  of  cubic 
centimeters  of  the  alkali  solution  used,  multiply  by  10  and  0.003G5  (the 
decinormal  factor  of  ITCl)  and  tlie  result  is  the  percentage  of  HCl.  If  suf- 
ficient material  is  at  liand,  tlie  estimation  should  be  repeated  to  avoid  pos- 
sible error. 

Lactic  Acid  (Uffelmann's  Test). — One  drop  of  the  solution  of  ferric 
chloride  is  added  to  20  cubic  centimeters  of  the  Vj  pci'  cent,  carbolic  acid 
solution;  this  is  diluted  till  a  transparent  amethyst  blue  color  is  obtained. 
A  few  dro])s  of  the  fluid  to  be  tested  added  to  a  few  cubic  centimeters  of 
this  solution  in  a  test-tube,  change  the  ainethyst-blue  to  a  canary-yellow  if 
lactic  acid  be  present.  On  account  of  the  presence  of  various  other  substances 
this  test  is  sometimes  not  distinctive  when  the  untreated  chyle  is  used.  A 
more  certain  procedure  is  to  add  to  lo  cubic  centimeters  of  the  filtered 
chvle   in   a   test-tube   110   cubic  centimeters  of  ether:    shake  tlioroughly  ; 


•  With  a  soft  flexible  catheter  I  syphon  the  gastric  eoutents  alKmt  two  lioiirs 
after  feeding;  if  the  stomach  is  irritable  and  chiklren  vomit,  then  the  vomited 
material  is  nsed. 

=  I  am  indebted  to  l?oas'  valnabh-  book  on  '•Diseases  of  the  Stoninch"  for  many 
points  in  the  chemical  examination  and  methods  used, 

(})1.-.) 


«)16  MISCELLANEOUS. 

allow  the  ether  to  separate;  decant  the  ether  into  a  clean  test-tube;  phice 
the  test-tube  containing  the  ether  in  a  glass  of  warm  water  till  the  ether 
has  evaj^orated ;  add  5  to  10  cubic  centimeters  of  distilled  water  to  ilie 
residue,  and  test  as  above  for  lactic  acid. 

Propeptone. — 'I'o  o  cubic  centimeters  of  chyle,  adtl  5  cubic  centimeters 
of  saturated  solution  of  sodium  chloride  and  2  drops  of  acetic  acid.  A 
cloudiness  or  precipitate  indicates  prope])tone,  especially  if  the  precipitate 
disappears  on  heating  and  returns  on  cooling.  ■ 

Peptone. — Filter  out  any  propeptone  from  the  last  named;  add  an 
excess  of  sodium  hydrate  solution;  mix  thoroughly  and  add  1  or  3  drops  of 
a  weak  solution  of  copper  sulphate  (V^  per  cent.);  the  appearance  of  a 
violet-red  or  old-rose  color  indicates  peptone.  This  is  the  so-called  l)iuret 
reaction  which  most  peptones  and  alljumoses  give. 

Pepsin. — For  this  test  we  require  uniform,  small  pieces  of  coagulated 
albumin;  these  should  be  little  circular  slices  of  hard  boiled  white  of  egg, 
1  centimeter  in  diameter  and  1  millimeter  in  thickness,,  which  may  be 
preserved  in  glycerine.  One  of  these  discs  is  placed  in  a  test-tube 
containing  5  cubic  centimeters  of  filtered  chyle  and  kept  at  a  temperature 
of  99°  F. ;  if  it  has  been  already  shown  that  hydrochloric  acid  is  absent, 
1  drop  or  3  of  dilute  hydrochloric  must  be  added.  The  tube  is  observed 
every  twenty  to  thirty  minutes  to  note  tlie  progress  of  digestion  and  th(> 
time  required  for  complete  disappearance  of  the  egg  albumin. 

Rennet.- — Add  a  few  drops  of  chyle  to  5  or  10  cubic  centimeters  of 
milk  and  ])lace  tube  in  water  at  a  temperature  of  99°   F. 

Motility. — The  motility  of  the  stomach  may  be  tested  in  various  ways ; 
probably  the  salol-test,  altliough  open  to  many  objections,  is  the  most  used. 

This  test  finds  the  foundation  for  its  use  in  the  fact  that  salol  is  not 
absorbed  until  it  reaches  the  alkaline  secretions  of  the  intestine,  by  which 
it  is  decomposed.  The  test  is  untrustworthy  when  the  stomach  secretion 
is  alkaline.  The  time  between  ingestion  and  the  appearance  of  salicyluric 
acid  in  the  urine  is  noted  by  examining  the  urine  at  intervals  of  one-half 
and  one  hour  after  taking  15  grains  of  salol  (immediately  after  meal). 
If  salicyluric  acid  l)e  present  in  the  urine,  the  addition  of  a  few  drops  of 
a  solution  of  ferric  chloride  gives  a  violet  co'or.  If  the  appearance  of  the 
test  be  delayed  longer  than  an  hour  or  an  liour  and  fifteen  minutes,  the 
motility  is  usually  considered  below  normal. 


CHAPTEll  IV. 
URINE. 

Method  of  Collecting  Ukixe. 

In  collecting-  urine  from  an  infant  we  can  apply  a  pad  of  sterile  ab- 
^iorbent  cotton  or  a  flat  sterile  sponge  to  tlie  vulva.  After  urination  the 
urine  absorbed  can  be  filtered  into  a  bottle.  If  the  urine  thus  secured  is 
not  sufficient  for  examination,  the  method  can  be  repeated  several  times. 
In  bovs  the  smallest, size  rubber  ice-bao-  can  he  drawn  over  the  genitals  and 
a  specimen  secured  in  this  manner. 

If  for  any  reason  this  method  cannot  be  carried  out,  and  it  is  vital 
that  the  examination  be  made,  then  an  infant's  size  catheter  may  be  used 
to  draw  off  the  urine. 

The  First  Urine. 

The  first  urine  drawn  by  catheter  is  acid,  almost  always  clear  and  but 
slightly  colored.  During  the  first  four  or  five  days  it  is  more  or  less  cloudy 
from  the  presence  of  epithelial  cells  from  the  urinary  passage,  and  uric 
acid  salts.  The  specific  gravity  averages  about  1013.  The  sediment  always 
contains  normal  epithelial  cells,  various  forms  of  uric  acid  crystals,  and 
now  and  then  hyaline  casts.  The  amount  of  urine  is  small  (Morse).  This 
is  due  in  part  only  to  the  insufficient  supply  of  milk,  as  the  amount  is  also 
small  in  bottle-fed  infants.  It  increases  rather  rapidly  about  the  fourth 
day,  20  to  50  cubic  centimeters  being  passed  in  the  first  three  days,  and 
about  100  cubic  centimeters  on  the  fourth  day.  In  the  second  week  it 
averages  between  200  and  300  cubic  centimeters. 

The  proportion  of  water  eliminated  in  the  urine  to  that  taken  in  the 
food  is  greater  after  the  fourth  day,  averaging  22  per  cent,  to  25  per  cent, 
before,  and  50  per  cent,  to  (50  per  cent,  after. 

TJie  urine  of  hreaat-fed  babies  almost  never  contains  indican,  that  of 
the  artificially  fed  baby  usually  but  slight  traces.  Urobilin  is  never  pres- 
ent in  that  of  the  breast-fed.  S(>ldom  in  that  of  the  artificially  fed.  It  does 
not  contain  albumin,  and  sugar  is  absent  with  the  ordinary  r(>agents.  The 
sediment  is  slight,  and  consists  entirely  of  colls.  One-third  to  one-halt" 
grain  of  ui'ea  ]icr  kilo  of  body  weight  is  said  to  be  jiasscd  in  twenty-four 
hours.  Figures  are  of  but  little  nse,  however,  as  the  amount  of  urea  vari<'s 
with  the  character  of  the  food.  It  is  jiretty  certain,  nevertheless,  that 
from  -10  to  50  per  cent,  of  llic  nitrog.'u  ingesicd  appears  in  ilic  urine. 
The  amount  of  urine  is   relatively  large.      It  varies  l»etween  200  miuI   500 

(itin 


918  MISCELLANEOUS. 


1 


cubic  ceutimeters  from  one  to  six  months,  and  between  250  and  600  cubic 
centimeters  up   to   2  years. 

The  urine  of  tlie  new-born  is  rich  in  sodium  cliloride,  which  salt 
diminishes  with  age.  During  the  first  and  second  months  of  life  it  is  in 
the  same  proportion  as  in  adults.  From  the  third  to  the  fifth  year,  com- 
puted by  kilogram  weight,  the  amount  is  O.bl:  gram;  at  11  years,  0.44 
gram,  and  at  IG  years,  0.18  gram. 

I'hos^jhoric  acid  is  seldom  found,  but  when  met  with  it  is  always  in 
very  minute  quantity.  1 

Uric  acid  is  present  in  the  earliest  urine,  and  the  quantity  regularly 
increases  up  to  the  third  day,  when  it  rapidly  diminishes. 

On  examining  the  kidneys  of  a  new-born,  the  papillae  will  be  found 
filled  with  a  reddish  substance  which  obstructs  the  urinary  ducts;  this, 
as  is  well  known,  is  nothing  more  than  uric  acid  infarction  and  has  no 
pathological  significance. 

Parrot  and  IJobin   found  urate  of  soda,   sulphate   of   calcium,   mag- 
nesium, potassium,  benzoic  acid,  allantoidin,  and  nmcin,  and  Cruse  denies 
the  presence  of  sugar,  oxalate  of  calcium,  or  hippuric  acid.     Creatinine   1 
and  indican  are  not  found  in  the  urine  of  the  new-born  or  wet-nursed. 
Xanthine  is  relatively  abundant  in  cases  of  nephritis. 

In  infantile  atrophy,  as  may  be  presumed,  the  quantity  of  urine  is 
far  below  the  normal;  it  is  yellow,  acid  reaction,  often  contains  organic 
deposits,  sugar,  albumin  and  an  excess  of  urea  and  phosphates. 

In  icterus  neonatorum  the  urine  is  pale-yellow,  and  contains  urates, 
epithelial  cells,  and  yellow  masses  of  pigment. 

The  urine  of  infants  with  scleroderma  is  reddish,  acid  with  uratic 
deposits,  and  slight  excess  of  urea. 

Albumin. 

The  presence  of  albumin  is  always  of  importance,  although  not  always 
due  to  an  inflammatory  process  of  the  kidneys.  Jt  is  often  the  sign  of  a 
simple  congestion  in  athrepsia,  cholera  infantum,  general  or  intestinal 
tuberculosis,  intestinal  catarrh,  typhoid  and  scarlet  fever. 

"A  small  amount  of  albumin  in  the  form  of  nucleo-albumin  is  almost 
constantly  present  in  the  urine  during  the  first  four  days  of  life.  It  often 
persists  for  two  w(>eks,  and  not  infreq\u'ntly  for  tAvo  months.  There  is 
much  difference  of  opinion  as  to  the  cause  of  this  albuminuria.  It  has 
been  attributed  to  the  changes  in  the  circulation  at  birth,  to  hyperjemia 
resulting  from  tlie  changes  in  the  metal)()lism  after  l)irth,  to  renal  disease 
in  the  mother,  and  to  irritation  from  uric  acid.  It  is  doubtful  if  any  of 
ihese  explanations  are  correct.  The  latest  investigations  show  tliat  albu- 
minuria is  no  more  common  in  the  children  of  women  suffering  from 
nephritis  or  eclampsia  than  in  others.     If  uric  acid  is  the  cause,  its  action 


THE    URINE. 


919 


is  probably  as  a  chemic  rather  than  as  a  mechanic  irritant.  Many  observ- 
ers regard  this  albuminuria  as  physiologic.  It  is  hardly  safe  to  consider 
it  so,  however,  until  more  is  known  about  metabolism,  the  changes  due  to 
nourishment,  and  disturbances  oi'  nutrition  in  the  new-born.  Whatever 
the  cause,  it  is  certainly  not  a  serious  condition,  and  ought  not  to  l^e  looked 
upon  as  the  forerunner  of  chronic  nephritis  in  later  life.*' 

In  older  children  the  presence  of  albumin  in  the  urine  is  always 
pathological,  except  when  it  is  the  physiological  result  of  the  administra- 
tion of  certain  drugs   (tincture  of  iodine,  etc.). 

A  slight  amount  of  albumin  may  be  found  in  nephritic  colic  due  to 
the  stimulus  which  the  uric  acid  exerts  upon  the  renal  parenchyma.  At 
other  times,  when  present,  there  is  an  actual  intlannnation  of  the  kidneys, 
as  in  scarlatina  and  diphtheria;  there  may  be  an  amyloid  degeneration 
without  its  being  possible  to  discover  any  albumin  in  the  urine. 

Sometimes  children  will  be  found  pale,  the  urine  perhaps  abundant 
or  diminished  in  quantity;  it  will  contain  albumin,  a  few  hyaline  casts, 
uric  acid  and  epithelium,  yet  they  will  have  good  appetite,  will  play  and 
appear  otherwise  quite  well.  Others  become  languid,  lose  their  appetite, 
complain  of  headaches,  painful  micturition,  and  will  pass  a  turbid  and 
sedimentous  urine.     In  these  cases  albumin  soon  appears. 

The  more  severe  cases  suffer  from  anuria;  partial  oedema  will  occur 
in  the  eyelids,  on  the  dorsum  of  the  foot,  etc.  The  next  day  the  amount 
of  urine  will  have  been  50  to  100  grams  in  twenty-four  hours.  This  will 
increase,  perhaps,  never  to  return  to  the  normal. 

The  color  of  the  urine  in  Bright's  disease  will  be  variable,  according 
to  the  amount  of  blood  which  it  may  contain,  of  acid  reaction,  and  average 
specific  gravity  of  lOlO  to  lOL").  Under  the  microscope  we  find  red  and 
white  corpuscles,  ha»matin,  renal  epithelium,  hyaline  or  granular  casts, 
uric  acid  crystals,  fat  glol)ules,  and  detritus. 

Chronic  nephritis  may  be  the  result  of  an  acute  affection  complicating 
scarlet  fever.  In  these  cases  children  suH'er  but  little  and  seldom  show 
more  than  a  few  cedematous  spots. 

These  forms  of  kidney  involvement  are  rather  rare,  and  cases  which 
have  been  diagnosed  as  such  have,  on  autopsy,  proven  to  have  l)een  cases 
of  amyloid  degeneration  due  to  syphilis,  malaria,  rachitis,  struma,  or 
tuberculosis. 

In  the  mild  forms  of  diphtheria  the  urine  sulVers  no  change  what- 
ever, but  in  the  general  infection,  even  in  the  early  stages,  all)uminuria  is 
found,  which  is  a  fairly  ])osilivc  evidence  of  systemic  infection.  If 
the  urine  diminishes  in  quantity  and  blood  corpuscles  are  found  under 
the  microscope  we  may  feel  sure  that  tlie  di|)htlieriti(!  process  luis  invaded 
the  kidney,  or  else  that  a  nephritis  complicates  the  diplitlieria. 

"In  rachitis,  albuminuria  is  comparatively  rare;  the  quantity  does  not 


920 


MISCELLANEOL'S. 


change  luatcrially,  but  the  calcium  salts  have  been  found  in  marked  dimin- 
ution. Marchand  and  Lehman  have  discovered  lactic  acid  present.  Th<' 
phospluitcs  and  chlorides  are  in  very  small  quantities.  The  urine  of  leu- 
kaemic  patients  at  times  contains  albumin  and  many  lymph  corpuscles  as 
well  as  hyaline  casts.  The  uric  acid  and  hypo.xanthine  are  in  greater 
quantity. 

"•Diabetes  mellitus  has  been  met  with  at  a  very  tender  age. 
"In  a  case  of  pseudo-hypertrophic  paralysis  Dennen  reports  marked 
glycosuria. 

"Hciemoglobinuria  is  found  in  "Winckel's  disease,  and  the  same  as  in 
adults,  in  malaria,  syphilis,  and  as  a  result  of  exposure  to  cold. 

''Ha?maturia  and  pyuria  have  no 
special  significance  bej'^ond  that  which 
they  have  in  adults. 

"Uric  acid  is  in  excess  during  the  |irst 
Aveek  and  is  a  physiological  phenomenon ; 
later  on,  deposits  of  urates  and  uric  acid 
appear  in  the  course  of  serious  diseases  of 
the  digestive  apparatus.  Under  other 
circumstances,  the  oxidation  of  nitrogen- 
ous substances  being  diminished  (by  dis- 
eases of  the  respiratory  or  central  nervous 
system),  deposits  of  oxalate  of  calcium 
occur. 

"Infarcts  of  uric  acid  may  be  found 
even  up  to  the  seventh  or  eighth  week. 
Children  will   strain,  make  repeated  ef- 
forts and  cry  out  during  urination;  the 
diapers    will    be    found    stained    with    a 
darker  urine  tlian  usual;  the  edges  of  the 
wet  surface  will   be  seen  reddened  by  a 
yellowish-pink  sandy  deposit.     A  careful 
analysis  of  this  urine  regularly  shows  an 
excess  of  uric  acid,  many  e])itlielial  cells, 
a  few  pus  corpuscles,  and  mucus  and  traces  of  albumin.     Quite  frequently 
the  urine  is  so  acid  as  to  produce  such  ])ronounced  evidences  of  pain  on  the 
part  of  the  infant  as  arc  met  with  in  the  nephritic  colic  of  adults. 

"When  tuljcrclo  bacilli  are  present  in  urinary  sediment,  the  diagnosis  of 
tuberculosis  of  the  kidneys,  ureters,  or  l)la(lder  may  be  positively  made. 
Care  should  l)e  exercised  not  to  confound  the  tubercle  bacillus  with  the 
smegma  bacillus,  which  may  often  l)e  present  in  the  same  specimen  of 
urine  and  which  stains  like  the  former,  thoufjh  it  decolorizes  differently. 


U)  (k) 

Fig.  301. — l>ino-Pyknonieter,' 
for  estimating  the  specific  gravity 
of  small  volumes  of  urine. 


^  It  can  be  procured  at  Einu-r  &  Amend,  cliemists'  supplies,  New  York  City. 


THE    URI^'E.  921 

"The  epithelium  foinid  in  iirinary  sediments  is  often  of  great  import- 
ance in  determining  in  what  part  of  the  genito-urinary  tract  the  lesion 
exists,  and  a  knowledge  of  the  histology  of  these  organs  will  sometimes 
prove  invaluable. 

"The  presence  of  echinoeoccus,  filaria,  etc.,  determines  the  exact  nature 
in  those  diseases. 

"Dysuria  is  not  always  a  manifestation  of  renal  or  vesical  disease,  since 
a  high  fever  may  at  times  originate  it.  In  such  cases  children  complain  or 
cry  out  on  attempting  to  urinate. 

"This  symptom  belongs  as  well  to  affections  of  the  external  genitals 
such  as  phimosis,  urethritis,  congenital  anomalies  of  the  urethra,  those  of 
the  labia  minora  in  females,  etc." 

Specific  Gravity. — The  specific  gravity  of  the  urine  is  best  taken  with 
a  hydrometer.  If  the  urine  is  very  scanty  an  instrument  called  the  urino- 
pyknometer,  devised  by  Dr.  Saxe,  should  be  used.  It  has  the  advantage  of 
giving  the  specific  gravity  when  only  1  drachm  or  3  cubic  centimeters  can 
be  procured. 

Test  for  Albumin. 

Place  in  a  test-tube  about  half  a  teaspoonful  of  pure  water,  in  which 
dissolve  one  of  the  potassio-mercuric  iodide  tablets  and  one  of  the  citric 
acid  tablets.  To  this  solution  gradually  add,  drop  by  drop,  the  urine.  If 
a  gelatinous  precipitate  occurs,  it  may  consist  of  albumin,  an  alkaloid 
such  as  quinine,  or  peptone.  To  determine  which  of  these  three  sub- 
stances was  originally''  present  in  the  urine,  heat  the  contents  of  the  tube 
to  the  boiling  point  and  note  if  the  precipitate  is  redissolved.  If  such  be 
the  case,  the  precipitation  was  due  to  peptone  and  not  albumin,  as  the 
latter  would  be  coagulated  and  would  not  be  dissolved.  If  the  precipitate 
consists  of  a  compound  of  the  reagent  with  an  alkaloid,  it  will  be  dis- 
solved completely  upon  the  addition  of  alcohol,  a  result  which  would  not 
occur  if  the  precipitate  consisted  of  all)umin.  The  potassio-mercuric  iodide 
test  is  exceedingly  sensitive,  and  -wlK'never  the  results  are  negative,  no 
precipitate  occurring  upon  the  addition  of  the  urine,  it  is  positive  evidence 
of  the  absence  not  only  of  albumin,  but  of  peptone  and  alkaloids  as  well. 
It  is  only  in  such  cases  where  a  preci))itate  occurs  that  it  becomes  necessary 
to  apply  alcohol  and  heat  tests  to  determine  the  character  of  the  precipi- 
tate. 

Direciinns  for  Use. — In  testing  urine  for  albumin  with  nitric  acid,  fill 
the  large  tube  of  the  horismasco])e  two-thirds  full  of  the  ni'ine,  which  must 
be  made  perfectly  clear  and  transparent,  if  necessary  by  filtration.  Then 
pour  into  the  funnel  tube  2~y  or  30  minims  of  nitric  acid,  which  will  pass 
down  through  the  capillary  tube  and  form  a  layer  underlying  the  urine. 


922 


MISCELLANEOUS. 


If  albumin  is  present,  a  distinct  white  zone  will  presently  appear  at  the 
point  of  contact,  sharply  defined  against  the  black  background,  the  amount 
of  albumin  being  indicated  by  the  dciij^ity  of  the  opaque  ring.  Sometimes 
air  will  remain  in  the  capillary  tube  of  the  instrument,  preventing  the  acid 
from  running  down  the  tube.  It  is  always  best  to  see  that  the  tube  is  free 
from  air  before  pouring  in  the  acid.  If  air  is  present,  it  can  generally  be 
driven  out  by  merely  tilting  the  instrument  or  it  may  be  driven  down  the 
tube  by  placing  the  thumb  or  middle  finger  on  top  of  the  funnel  so  as  to 
cover  it  completely  and  pressing  quickly  and  forcibly  so  as  to  cause  a  few 
bubbles  of  air  to  pass  through  the  urine. 

In  the  use  of  the  horismascope  in 
applying  the  nitric-acid  test  for  albu- 
min, these  advantages  are  secured: 

1.  The  acid  when  it  comes  in  con- 
tact with  the  urine  is  of  full  strength, 
rendering  the  test  much  more  delicate 
than  as  ordinarily  applied. 

2.  The  reaction  is  not  liable  to  be 
obscured  by  separation  of  uric  acid  or 
acid  urates,  such  separation  not  taking 
place  in  the  horismascope  until  after 
a  considerable  interval. 

3.  The  black  and  white  back- 
grounds of  the  instrument  render  much 
more  distinct  the  effects  produced  by 
the  reagent. 

4.  No  especial  skill  is  required  on 
the  ])art  of  the  operator. 

The  faintest  visible  trace  of  al- 
bumin as  shown  by  the  nitric  acid 
test  may  l)e  stated  to  be  Voo  P^r  cent. 
One-fourth  of  1  per  cent,  is  just  suffi- 
cient to  make  the  albumin  layer  opaque  when  vieAved  from  above.  If  larger 
amounts  are  present  the  percentage  may  be  approximately  estimated  by 
diluting  the  urine  until  the  opacity  is  reduced  to  that  corresponding  with 
0.35  per  cent. 

There  are  many  other  tests  which  can  be  advantageously  made  by 
introducing  the  reagent  from  beneath,  allowing  it  thus  to  form  a  distinct 
stratum  underlying  the  fluid  to  l)e  tested. 

In  testing  a  specimen  of  urine  it  is  always  l)est  to  first  determine  its 
reaction.  For  this  ])urpose  red  and  blue  litmus  paper  should  always  be  at 
hand.  A  small  piece  of  each  kind  of  paper  should  be  added  to  the  specimen 
and  the  result  be  observed.     If  tlic  urine  is  alkaline  the  red  litmus  paper 


Fig.  302. — The  Horismascope  or  Albuiiio- 
scope.  A  new  instrument  for  determining  the 
presence  and  amount  of  albumin  in  theurine. 
Xo  liability  of  the  acid  mixing  with  theurine. 
The  slightest  visible  trace  of  albumin  can  be  in- 
stantly detected  against  the  dark  background. 
Color  reactions  due  to  urinary  and  biliary  pig- 
ments are  clearly  shown  against  the  white 
backgrjund. 


THE    URKNE.  923 

v\ill  turn  blue,  and  if  it  is  acid  the  blue  litmus  paper  will  turn  red.  It  is 
very  important  that  when  testing  for  sugar  the  urine  should  be  slightly 
alkaline,  and  when  testing  for  albumin  it  should  be  slightly  acid.  In  order 
to  render  the  specimen  slightly  alkaline  or  slightly  acid  according  to  the 
test  that  is  to  be  applied,  sodium  carbonate  tablets  and  citric  acid  tablets 
should  be  used. 

Robert's  Albumin  Test. 

R  Sat.  sol.  magnes.  sulph.  (c.  p.) 5  ounces 

Nitric  acid  (c.  p.) 1  ounce 

This  test  is  a  cold  one,  viz. :  put  about  1  cubic  centimeter  of  solution 
into  medium-sized  test-tube — incline  on  a  steady  rest  on  an  angle  of  45 
degrees.  With  a  slender  pipette  allow  the  filtered  urine  to  be  tested — to 
flow  very  slowly  down  the  side  of  the  tube.  It  will  float  above  test  solution. 
Use  about  1  cubic  centimeter  of  urine.  Examine  in  front  of  the  window 
by  daylight,  with  aid  of  black  background.  A  sharp  clear-cut,  white  line 
will  appear  at  contact  line  if  albumin  is  present.  A  wide  band  of  white 
is  not  always  indicative  of  albumin,  neither  is  a  narrow  zone  above  in  the 
urine,  which  may  be  due  to  mucus.    The  sharp,  clear-cut  zone  is  distinctive. 

A  New  Test  for  Albumin.^ — This  new  and  simple  test  is  based  upon  the 
following  facts : — 

1.  Allmmin  is  coagulated  by  carbolic  acid. 

2.  Equal  volumes  of  non-albuminous  urine  and  a  mixture,  composed 
of  equal  parts  of  carbolic  acid  and  glycerine,  form  an  emulsion  which  clears 
up  entirely  upon  agitation,  leaving  a  perfectly  transparent  and  highly  re- 
fractive liquid. 

3.  p]qual  volumes  of  albuminous  urine  and  the  above  mentioned  carl)ol- 
glycerine  solution,  when  mixed  together,  produce  a  white  turbidity,  which 
remains,  in  spite  of  agitation,  and  does  not  precipitate  on  standing  nor 
rcdissolve. 

The  test  is  very  sensitive,  distinctly  showing  the  presence  of  0.1  per 
cent,  of  albumin  in  the  urine,  the  degree  of  turbidity  being  proportionate 
to  the  percentage  of  albumin  contained  in  the  urine. 

Test. — Two  cul)ic  centimeters  of  carbol-glycerine  solution  are  poured 
into  a  small  test-tube,  and  2  cubic  centimeters  of  the  filtered  urine  are 
added,  !^^ix  thoroughly  with  a  ghiss  rod,  or  agitate.  If  a  clear,  transparent 
liquid  results,  there  is  no  all)Uiiiin  present;  but  if  the  slightest  turbidity  is 
noticeable  Ibc  urin«'  is  albuminous. 

The  Diazo  Reaction  in  Urine. — The  diazo  test  was  suggested  by 
Ehrlich.  in  188'i,  as  a  valuable  diagnostic  measure  in  typhoid  fever,  al- 
though he  admitted  the  occurrence  of  this  reaction  in  a  few  other  con- 
ditions shortlv  to  bo  considered. 


*Fuhs,  Medical  Record,  ^farc  h   S.  1002. 


924  MISCELLANEOUS. 

The  diazo  reaction  depends  upon  the  fact  that  if  sulphanilic  acid 
(amidosulphobenzol)  be  acted  upon  by  HNO,  diazosulphobenzol  is  formed, 
which  \mites  with  certain  aromatic  substances  occasionally  jiresent  in  the 
urine  to  form  aniline  colors. 

Friedenwald  has  recently  reviewed  the  literature  of  this  reaction, 
and  showed  that  many  of  the  contradictory  results  obtained  by  some  ob- 
servers are  due  to  failure  in  carrying  out  Ehrliclr's  methods  in  performing 
the  test,  which  is  best  accomplished  as  follows : — 

To  obtain  diazosulpholienzol  in  a  perfectly  fresh  condition  sulphanilic 
acid  is  kept  in  solution  with  hydrochloric  acid;  to  this  sodium  nitrate  is 
added,  whereupon  HNO  is  liberated  and  diazosulphobenzol  is  formed. 

Process. — Two  solutions  are  prepared,  as  follows: — 

1.  Two  grams  of  sulphanilic  acid,  50  cubic  centimeters  of  hydrochloric 
acid,  1000  cubic  centimeters  of  distilled  water. 

2.  A  0.5  per  cent,  solution  of  sodium   nitrilc. 

In  performing  the  test,  50  parts  of  ISTo.  1  and  1  part  of  No.  2  arc 
mixed,  and  eqmil  parts  of  this  mixture  and  of  the  urine  in  a  test-tube  are 
rendered  strongly  alkaline  with  ammonia.  If  the  reaction  be  positive  the 
solution  assumes  a  carmine-red  color,  which  on  shaking  must  also  appear 
on  the  foam.  Upon  standing  for  twenty-four  hours  a  greenish  precipitate 
is  formed. 

The  test  must  not  be  considered  positive  unless  a  distinct  red  colora- 
tion extends  to  and  includes  the  foam  on  shaking. 

Diazo  Reaction  in  Nurslings  and  Children. — "The  diazo  reaction  never 
appears  in  the  urine  of  healthy  nurslings. 

"High  temperatures  in  children  do  not  affect  the  reaction. 

"Catan-hal  pneumonia  (acute)  and  also  chronic  does  not  give  the 
reaction. 

"Diphtheria  and  varicella  do  not  give  this  reaction. 

"Otitis,  coryza,  lymph-adenitis,  omphalitis,  bronchial  catarrh,  pleu- 
ritis,  gastro-intestinal  catarrh,  colitis,  congenital  syphilis,  eczema,  and 
erythema  give  no  reaction. 

"Erysipelas  and  niorl)illi  almost  always  give  this  reaction. 

"The  severer  the  attack  of  erysipelas  or  measles,  the  more  pronounced 
the  reaction,  and  when  intensity  of  the  disease  vanishes  the  reaction  looses 
its  strength.  In  lethal  cases  the  reaction  remains  until  death  is  plainlv 
pronounced.  Therefore  the  inienslty  of  tJic  disease  and  the  reaction  go 
hand  in  hand. 

"The  reactitm  can  be  found  in  tlie  urine  of  nurslings  one  or  two  days 
before  exitus,  no  matter,  what  the  nature  of  the  disease. 

"The  prognosis  can  at  iinu>s  be  guided  by  the  intensity  of  the  reac- 
tion, for  the  more  severe  tlie  disease  the  greater  the  reaction. 

"The  reaction  is  most   commonly   found   in  typhoid   fever   from  the 


THE    URI^'E.  925 

fourth  to  the  seventh  clay  and  thereafter,  and  if  the  reaction  be  absent  the 
diagnosis  is  doubtfuh 

"Cases  of  typhoid  fever  characterized  by  faint  reaction  and  occur- 
ring only  for  a  short  time  may  be  predicted  to  be  of  very  mild  type. 

"The  reaction  is  occasionally  noted  in  phthisis  pulmonalis,  but  only 
in  cases  pursuing  a  rapid  course  toward  a  fatal  termination. 

"The  reaction  is  sometimes,  but  not  often,  observed  in  cases  of  measles, 
miliary  tuberculosis,  pyemia,  scarlet  fever,  and  erysipelas. 

"In  diseases  unaccompanied  by  fever,  as  chlorosis,  hydrasniia,  dia- 
betes, diseases  of  the  brain,  spinal  cord,  liver,  and  kidneys,  the  reaction  is 
always  absent."' 

The  weight  of  clinical  evidence  strongly  confirms  all  of  Ehrlich's 
original  claims  for  this  reaction,  but  more  especially  so  witli  regard  to 
typhoid  fever  and  pulmonary  tuberculosis;  if  present  in  the  latter  disease 
any  length  of  time,  the  prognosis  is  very  unfavorable. 

Indican. 

Detection  of  Indican. — Jaffe's  method  consists  in  mixing  10  cubic  cen- 
timeters of  strong  hydrochloric  acid  with  an  equal  volume  of  urine  in  a 
test-tube,  and,  while  shaking,  add  drop  by  drop  a  perfectly  fresh,  saturated 
solution  of  chloride  of  lime,  or  chlorine  water,  until  the  deepest  obtainable 
blue  color  is  reached.  The  mixture  may  next  be  titrated  with  chloroform, 
which  readily  takes  up  the  indican  and  holds  it  in  solution,  and  the  quan- 
tity present  may  be  approximately  estimated  according  to  the  depth  of 
the  color.  If  the  urine  contains  albumin  it  should  be  removed  before 
applying  this  test,  otherwise  the  blue  color,  often  arising  from  the  mixture 
of  hydrochloric  acid  and  albumin  after  standing,  may  prove  misleading. 

Tkst  Foi!  SioAi;  ((Jh'cose)  in  Urine. 

The  best  test  for  sugar  is  furnished  by  the  indigo  and  sodium  car- 
bonate tablets.  This  test  is  applied  by  first  placing  in  a  test-tube  about 
half  a  teaspoonful  of  water,  one  of  the  indigo  and  sodium  carbonate  tab- 
lets, and  one  of  the  sodium  carbonate  tablets.  Heat  the  contents  of  the 
tube  gently  until  solution  is  elTected,  and  then  add  1  drop  of  the  urine  to 
be  tested,  keeping  the  fluid  at  the  boiling  point  without  allowing  it  to  boil. 
If  no  effect  is  produced  add  a  second  drop  of  the  urine  and  heat  as  before. 
If  no  change  of  color  results  add  another  drop  of  the  specimen,  and  so  on 
until  at  least  five  drops  have  been  added.  If  any  notable  amount  of  sugar 
is  present,  one  or  at  least  two  drops  will  suirue  to  bring  about  the  reaction. 
The  fluid  will  change  from  pure  blue  to  amethyst,  then  to  ]iurple  and  red, 
finally  fading  to  a  pale  yellow.     If  the  quantity  of  sugar  is  very  small,  the 


926 


MISCELLANEOUS. 


color  will  change  only  to  a  })ur})le  or  red,  and  in  nearly  every  case  five  drops 
oj'  normal  urine  will  produce  this  change. 

If  one  drop  of  the  urine  prochices  a  strong  reaction,  dilute  the  urine 
to  one-half,  one-quarter,  one-eighth,  etc.,  in  succession  until  a  single  drop 
ceases  to  produce  a  visible  change,  and  estimate  roughly  in  this  manner 
the  quantity  of  sugar  present.  While  observing  the  various  changes  of 
color  which  the  liquid  undergoes,  if  sugar  is  present,  any  agitation  of  the 
solution  should  be  carefully  avoided.  The  reason  for  this  precaution  is 
readily  explained  by  the  fact  that  the  original  blue  color  of  the  solution 
may  be  restored  by  simply  shaking  the  liijuid.  This  remarkable  eft'ect  is 
not  due  to  cooling,  but  to  the  oxidizing  influence  of  the  air. 

In  regard  to  the  comparative  value  of  tests  for  sugar,  it  may  be  said 
that  the  copper  test  is  the  least  trustworthy.  Among  the  normal  constit- 
uents of  the  urine,  uric  acid  is  capable  of  reducing  copper  compounds,  and 
numerous  substances  which  may  accidentally  be  present  have  a  similar 
action.  The  indigo  test  is  capable  of  detecting  a  smaller  quantity  of  sugar 
in  the  urine  than  any  other  reagent.  One  drop  of  a  solution  of  glucose, 
containing  a  half  grain  to  the  fluidounce,  shows  a  distinct  reaction. 

Whitney's  Test  (for  Sugar).'  —  The  following  table  will  give  the 
amount  of  sugar  in  analvtical  testing: — 


Table  No.  106. 


If  Reduce  J  by 

It  Contains  to  the  Ounce 

Percentage. 

1  minim 

16.0    grains  or  more 

3.33 

2  minims 

8.0    grains 

1.67 

3 

5.33      " 

1.11 

4 

4.0        " 

().H3 

5 

3.20      " 

0.67 

6 

2.67      " 

0.56 

7 

2.29      " 

0.48 

8 

2.0        " 

0.42 

9 

1.78  gram 

0.37 

10 

1.60      " 

0.33 

The  Method  of  Procedure. — Heat  1  drachm  of  the  reagent  in  a  test- 
tube  to  boiling;  add  the  urine  slowly,  drop  by  drop,  until  the  blue  color 
begins  to  fade;  then  more  slowly,  boiling  three  to  five  seconds  after  each 
drop,  until  the  reagent  be  perfectly  colorless,  like  umter,.  or  until  10  drops 
only  are  added. 

It  will  be  noted  after  reduction  that  the  reagent,  on  cooling,  resumes 
the  blue  color  again.  This  change  is  due  to  the  absorption  of  oxygen  from 
the  atmosphere,  changing  the  reduced  suboxide  held  in  solution  to  the  blue 


^  Physicans  can  procure  the  reagent,  accurately  compounded  as  described,  from 
tlie  Lewis  Chemical  Company. 


THE   LHIXE. 


1)27 


protoxide  again.  This  sliould  imt  ])r  mistaken  for  iinporfect  reduction  or 
defect  in  the  reagent.  Tlie  cliange  takes  pUue  quickly  Ijy  sliaking  the  tube, 
and  tlie  reduction  can  be  repeated,  if  done  immediately,  Ijefore  the  evapo- 
ration of  the  ammonia  by  the  addition  of  the  saccharine  urine  as  before, 
thougli  not  with  the  same  degree  of  accuracy. 

When  a  specimen  of  saccharine  urine  contains  a  large  amount  of  albu- 
min, the  reduction  takes  place  without  interference  l)y  the  albumin  present, 
but  leaves  the  reagent  more  or  less  of  a  yellow  tint,  according  to  the 
amount.  A  large  amount  of  coloring  matter  has  a  similar  effect,  but  there 
is  little  danger  of  uncertainty  when  not  more  than  ten  minims  are  used. 

Fermentation  Test. — With  the  aid  of  a  saccharometer  we  have  a  con- 
venient method  of  estimating  the  quantity  of  sugar  in  the  urine.  A  piece 
of  yeast-cake  about  the  size  of  a  pea  is  added  to  a  test-tube  of  urine,  and 
allowed  to  stand  at  a  temperature  of  90°  F.  If  sugar  is  present,  yeast 
transforms  it  into  alcohol  and  carbon  dioxide,  by  fermentation.  While  this 
test  is  reliable,  it  is  not  a  very  delicate  one. 


CHAPTER  V. 
BACTERIOLOGICAL  MEMORANDA.* 

Demonstration  of  Tubercle  Bacilli  in  Sputum. 

With  a  forceps  pick  out  a  thick,  purulent  portion  of  the  sputum. 
Make  a  thin  spread  between  a  slide  and  a  cover-glass.  i\.llow  this  to  dry 
thorouglily  in  the  air  or  it  can  be  dried  by  holding  it  several  inches  above 
a  Bunsen  burner.  Stain  with  several  drops  of  Ziehrs  solution  and  heat 
it  over  a  Bunsen  burner: — 

Ziehl's  solution : — 

IJ  Fuchsin-    1  gram 

Alcohol    10  grams 

Carbolic  acid   5  grams 

Water    100  grams 

After  heating  wasli  the  cover-glass  in  water,  and  lastly  add  several 
drops  of  (iabbet-J^]rnst  solution : — 

IJ  Methylene   blue 2  grams 

Diluted  sulphuric  acid  (25  per  cent.) 100  grama 

_ Rinse  this  solution  off  the  cover-glass,  dry  between  filter  paper,  and 
mount  with  Canada  balsam. 

Under  the  immersion  lens  the  tubercle  bacilli  will  be  stained  red,  and 
all  other  bacteria  will  have  the  blue  background. 

Aqueous  Solutions. — Aqueous  solutions  of  methyl  violet,  gentian  vio- 
let, fuchsin,  and  the  other  aniline  dyes  are  prepared  by  adding  1  cubic  cen- 
timeter of  the  saturated  alcoholic  solutions  of  the  desired  dye  to  20  cubic 
centimeters  of  distilled  water.  This  will  impart  a  decided  color  to  the 
liquid  so  that  a  pipette  full  will  be  barely  transparent. 

The  true  aqueous  solutions  are  made  by  dissolving  the  dyes  in  water, 
but  these  are  weak  and  not  so  effective  as  those  prepared  from  the  alcoholic 
solutions.  These  solutions  deteriorate  in  a  short  time.  The  carbol-fuchsin 
and  alkaline  methylene  blue  will  keep  a  little  longer,  but  they  require  to 
be  filtered  occasionally. 


'The  reader  is  referred  to  works  on   bacteriology    (such   as  Lonhartz-T?roolcs) 
for  blood  examinations  in  malaria,  anajmia,   leukajmia,  and  for  the  Widal  reaction 
of  the  blood  in  typhoid  fever. 
(928) 


BACTERIOLOGICAL    MEaiORANDA.  929 

Goxococcus, 

With  a  platinum  loop  pick  out  a  thick  purulent  portion  of  the  discharge. 
Make  a  thin  spread  between  two  slides.  Dry  in  the  air  or  over  a  Bunsen 
burner.  Stain  with  "methylene  blue  for  half  a  minute.  Rinse  this  solu- 
tion off  the  slide.     Dry  between  filter  paper  and  mount  with  Canada  balsam. 

DiPLOCOCCUS    PXEUMONI^. 

With  a  platinum  loop  pick  out  a  thick  portion  of  the  sputum.  Make 
a  thin  spread  between  two  cover-glasses.  Immerse  in  a  watch-glass  of  ani- 
line gentian  violet  for  ten  minutes.  Pass  through  water,  and  place  in 
Gram's  iodine  solution  for  five  minutes.  Wash  in  alcohol  until  no  fur- 
tlier  color  comes  awa3^     Place  on  edge  to  dry.     Mount  in  Canada  balsam. 

Klebs-Loeffler  Bacillus. 

Bacteriological  method  of  diagnosis  is  given  in  detail  in  chapter  on 
"Diphtheria."     Bacillus  stains  well  with  Loeffler's  alkaline  methylene  blue. 

,  Streptococcus. 

Usually  found  in  purulent  ear,  eye,  or  nasal  discharges,  sometimes  in 
vaginitis. 

With  a  platinum  loop  pick  out  a  thick  portion  of  the  discharge.  Make 
a  thin  spread  between  two  slides.  Dry  in  the  air  or  over  a  Bunsen  burner. 
Stain  with  methylene  blue  or  fuchsin  solution.     Mount  in  Canada  balsam. 

Menixgococcus. 

Lumbar  puncture  fluid  in  cerebro-spinal  meningitis  should  be  spread 
between  two  cover-glasses  and  dried  over  a  Bunsen  burner.  Stain  with 
methylene  blue.     Mount  in  Canada  balsam. 


CHAPTP]R  VI. 

ANESTHETICS   IN   CHILDRExN'. 

Nitrous  Oxide  and  Ether. 

The  ideal  ana^stlictie  for  diildfen  is  a  coinl)ination  of  nitrous  oxide 
and  ether.  Whenever  it  is  possible  one  skilled  in  its  administration  should 
he  employed.  Tlie  responsihiliti/  of  attending  to  a  major  or  minor  opera- 
tion is  so  (j-reat  that  unless  one  sl-illed  in  the  administration  of  an  ana>s- 
thetic  is  employed  there  may  be  serious  after-effects.  To  properly  giiard 
the  heart  and  respiration  requires  experience,  and  no  surgeon  should  un- 
dertake to  do  both,  excepting  in  extreme  emergencies. 


Fiji;.  ;50;j. — Gas  and  Ellior  Inhaler. 


Walter  K..  o  years  old.  was  given  a  mixture  of  nitrons  oxide  and  ether  hy  Dr. 
Culler.  Tiie  ciiild  was  aiiit'stheti/ed  without  a  struggle.  1  removed  tlie  adenoids 
and  liy|icrlroi)liie(l  tonsils.  The  cliild  showed  r.o  evidence  of  shock.  There  was 
.slight  nausea.  No  other  evidence  of  gastric  disturbance.  There  were  no  after- 
eflects. 


Chloroform. 

Chloroform  vapor  is  decomposed  into  chlorine  and  hydrochloric  acid 
by  the  presence  of  the  common  gas  flame,  and  may  thus  give  rise  to  irri- 
tating effects  upon  the  respiratory  organs. 
(930) 


AN.ERTTIKTICS.  931 

When  employed  it  should  he  ndiuinistered  by  the  drop  method.  By 
this  method,  combined  with  fresh  air,  tlie  danger  is  minimized.  The  statis- 
tics of  Dr.  George  Gould,  of  Philadelphia,  and  the  Lancet  Commissioner, 
])rove  that  chloroform  anaesthesia  causes  more  deaths  than  ether  as  an 
anesthetic. 

Ethyl  Chloride. 

This  is  an  excellent  ana'sthetic  and  can  be  administered  as  a  spray  on 
a  chloroform  mask.  I  have  frecpiently  used  it  in  my  hospital  service  to 
remove  adenoids,  tonsils,  and  for  a  circumcision.  Ethyl  chloride  is  a  rapid 
and  safe  anasthetic. 

Local  Ana'silirsifi. — Ethyl  chloride,  as  a  spray  until  the  part  is  frozen, 
is  sufficient  to  open  an  abscess,  for  a  lumbar  puncture,  or  even  an  empyema, 
in  a  sensitive  child,  or  where  general  anasthesia  is  contraindicated. 

Etiiek. 

Sulphuric  ether,  used  alone  as  an  anfesthetic  in  children,  may  be 
considered.  It  requires  a  much  longer  time  to  produce  its  effect, 
although  it  has  no  depressing  effect  upon  the  heart.  Statistics  show  that 
in  ;i()0,lTo  administrations  of  ether  there  were  18  deaths.  Out  of  638,461 
of  chloroform,  there  were  160  deaths,  showing  the  following  ratio: — 

Chloiofonn     mortality     1   to     .3.749 

VAhvv    mortality     1   to   16.G75 

We  therefore  see  that  ether  is  by  far  the  safer  anasthetic.  Weir  states 
that  "ether  narcosis  is  safer,  even  though  the  kidneys  are  slightly  affected." 
Ether  is  frequently  combined  with  oxygen,  and,  as  previously  stated,  with 
laughing  gas,  and  forms  in  the  latter  coml)ination  ///"  saf<'-'<i  (tiif/'si/icfic  for 
chilchen. 

Rcf/ardiini  I  he  Effect  of  Elhcr  in  AffccHoiis  of  the  Air  Pasmgcs. — 
AlTections  of  the  air  ])assages  following  etbei'  uarcosis  are  usually  the  result 
of  aspiration  of  infected  mouth  contents.  Ether  causes  a  slight  increase  of 
mucous  secretion.  It  has  no  ii'i'itant  action  on  the  tracheal  or  bronchial 
mucous  menibi'aHc.  \\  hen  bronchitis  or  |)iu'um()nia  exists,  greater  care 
must  be  taken  owing  to  the  increased  secretion  produced  by  the  ether,  as 
stated  above.  When  nitrous  oxide  is  given  we  avoid  the  iri'itant  ofTect  just 
described. 

fii  ailciioifl  o/icnilloiis.  give  nitrous  oxide  until  cyanosis  is  seen,  then 
give  ether:   the  change  relieves  cyanosis  at  once. 

Ei/ni}ili<ilir  h'nhirficiiiciil  In  Chih/rcii. — Most  deaths  occui'  in  children 
in  which  the  lyjiiphatic  condition  exists — the  so-called  lymphatic  diathesis. 

'J'he  Childreirs  Clinic  at  Graz.  diiring  the  last  twenty  years,  shows 
that  records  of   fatalities  with   chloroform    always   revealed   the   lymi)liati(e 


932  MISCELLANEOUS. 

hyperplasia,  which  is  the  principal  feature  of  the  so-called  constitutio  lym- 
phatica,     (Ecad  chapter  on  "Status  Lymphaticus/') 

Ewiug  helievcs  the  above  conditions  prevail  in  America.  Lartigan's 
report  of  the  lloosevelt  Hospital  shows  that  death  came  after  ether  as  well 
as  after  chloroform,  in  children  affected  by  the  lymphatic  constitution. 

The  presence  of  universal  enlargement  of  the  lymph  nodes  without 
direct  inflammatory  cause,  hypertrophied  tonsils,  adenoid  hyperplasia, 
tendencies  to  anaemia,  weakness  of  pulse,  irregular  heart's  action,  along 
with' insufficient  development  of  the  heart  and  large  blood-vessels,  show 
that  the  lymphatic  condition  exists. 

Local  An.ijisthesia  by  the  Injection  of  Sterile  Water.^ 

When  the  heart,  lungs,  or  kidneys  contraindicate  the  use  of  a  general 
anaesthetic,  then  local  angesthesia  should  be  tried.  Gant  advises  the  use  of 
regional  injections  of  sterile  water  in  the  part  to  be  incised.  He  claims 
that  an  abscess  can  be  opened  or  similar  surgical  work  performed  without 
pain  by  this  means.     It  is  well  worth  trying. 

Intra-spinal  An.55STHESIA.^ 

Corning,  of  New  York,  about  twenty  years  ago  found  that  anaesthesia 
could  be  produced  in  the  lower  part  of  the  body  by  injecting  cocaine  in  the 
lumbar  region  of  the  spine.  The  patient  is  placed  in  a  sitting  position 
well  bent  forward,  and  firmly  held  during  the  injection.  The  skin  should 
be  cleaned  in  the  usual  antiseptic  way,  followed  by  an  ethyl  chloride  spray. 
This  renders  the  introduction  of  the  needle  practically  painless.  A  point 
one-half  inch  to  either  side  of  the  median  line  and  midway  between  the 
spinous  processes  is  taken,  and  the  needle  pushed  forward,  inward,  and 
upward.  Special  effort  is  made  to  keep  away  from  the  central  part  of 
the  spinal  canal  by  a  close  relation  of  the  needle  point  to  the  dura.  The 
instrument  used  is  of  the  simplest  kind.  A  small-sized,  steel  aspirating 
needle  with  a  short-beveled  pointed  end,  having  a  well-fitted  hypodermic 
barrel,  answers  every  purpose.  As  nearly  as  possible  the  same  amount  of 
cerebro-spinal  fluid  is  allowed  to  escape  as  of  the  injection  medium  which 
is  to  be  introduced.  The  injection  is  given  slowly,  usually  taking  one  and 
one-half  to  two  and  one-half  minutes.  Often  the  first  evidence  that  the 
cocaine  is  taking  effect  is  some  dilatation  of  the  pupils  or  a  slight  nausea. 

This  method  has  been  especially  valuable  where  circumcision  is  to  be 
performed,  or  where  the  examination  of  the  bladder  is  to  be  made.     In 


^For  details  of  this  method,  see  article  of  Gant's,  published  in  the  New  York 
Medical  Journal,  January  23,  1904. 

-  Tlie  tecliniqiie  of  lumbar  puncture  is  described  in  article  on  "Meningitis" 
(page  827). 


ANESTHETICS.  933 

children  I  have  frequently  found  considerable  nausea  and  vomiting  fol- 
lowing the  use  of  cocaine;  the  same  is  also  true  of  eucaine.  The  analgesic 
eifect  of  eucaine  is  in  some  cases  as  good  as  that  of  cocaine. 

Dose  Required. — Five,  rarely  ten  minims  of  freshly  prepared  2  per 
cent,  cocaine  solution  are  required.  The  solution  should  be  freshly  pre- 
pared for  each  case,  by  dissolving  the  eucaine  or  cocaine  in  sterile  water. 
It  is  well  to  remember  that  there  are  certain  toxic  effects  noted  in  some 
children.  This  should  be  borne  in  mind,  and  individual  idiosyncrasies 
noted. 


CHAPTER  VII. 
DISINFECTION. 

We  know  that  pathogenic  bacteria  abound  in  the  false  membrane,  in 
the  sputa,  and  in  the  secretions  of  the  diseased  mucous  membrane,  and 
also  in  the  stools  and  urine.  Physicians  and  nurses  are  particularly  ex- 
posed to  the  danger  of  infection  when  examining  or  swabbing  the  throats 
of  patients,  through  the  coughing  of  mucus  or  particles  of  membrane  into 
their  faces.  Bacilli  frequently  abound  in  the  form  of  dust.  They  can  with- 
stand drying  fourteen  days.  They  nuiy  retain  their  virulence  four  to  seven 
months,  in  dark,  damp,  and  cold  places. 

Disinfections  to  be  Used  as  Means  of  Prevention. — As  a  ineans  of 
prevention  the  following  may  be  recommended: — 

Corrosive  sublimate    1  to  10,000 

Cyanide  of  mercury   1  to  10,000 

Chloroform  water.^ 

2  per  cent,  carbolic  acid  in  30  per  cent,  alcohol. 

Turpentine  and  alcohol  equal  parts  with  2  per  cent,  carbolic  acid  added. 

The  above  solutions  are  to  l)o  used  to  prevent  the  development  of  the 
bacilli  on  the  adjacent  mucous  membrane.  Great  care  should  be  taken 
in  using  poisonous  solutions  in  the  treatment  of  children. 

Paraform  is  extensively  used  and  recommended. 

Clinical  thermometers  and  all  instruments  should  be  disinfected  in 
carbolic  acid  solution  immediately  after  being  used.  The  nurse  or  at- 
tendant on  the  patient  should  observe  the  same  precautions  as  the  phy- 
sician, who.  after  handling  the  patient  or  touching  anything  about  him, 
should  disinfect  his  hands  in  a  l)asin  of  3  per  cent,  carbolic  solution,  which 
together  with  a  nail-brush  should  l)e  kept  constantly  on  hand  in  the  sick 
room.  When  practicable,  a  room  at  the  top  of  the  house  sliould  be  chosen 
in  which  to  place  the  patient.  All  superfluous  objects,  curtains,  carpets, 
ornaments,  etc.,  which  are  liable  to  catch  dust  should  be  removed,  only 
articles  necessary  for  the  patient's  comfort  being  left  in  the  room.  Good 
ventilation  must  be  maintained.  A  sheet  kept  constantly  moistened  with 
carbolic  acid  solution  should  be  tacked  in  the  doorway,  nuiking  it  necessary 
to  push  it  to  one  side  in  going  in  and  out  of  the  room,  thus  making  the 


'  f'hloroforni  water  is  made  by  saturating  a  pint  of  water  with  a  drachm  or  2  of 
pure  ehlorofonti  and  pouring  oflF,  after  several  vigorous  shakings,  so  that  none  of  the 
chloroform  passes  over. 
(934) 


DISINFECTION.  935 

isolation  more  perfect.  All  children  belonging  to  a  family  in  which  an 
infectious  disease  has  occurred  should  be  prevented  from  attending  school 
for  a  shorter  or  longer  period,  never  less  than  four  weeks. 

The  presence  of  injects  in  the  sick  room,  especially  flies,  should  be 
guarded  against  as  much  as  possible,  in  view  of  the  fact  that  they  may 
act  as  carriers  of  the  disease.  Xo  food  should  be  allowed  to  stand  uncov- 
ered in  the  sick  room,  as  in  certain  cases  pathogenic  organisms  may  gain 
access  and  multiply  therein. 

Sputa  are  best  disinfected  by  steam  sterilization,  together  with  the 
sputum  cups.  The  addition  of  15  grams  of  sal-soda  to  a  liter  of  water 
materially  aids  the  process  of  cleaning. 

Urine  and  fa'ces  are  best  treated  together  by  means  of  milk  of  lime 
In  this  we  possess  the  most  valuable  agent  for  the  .disinfection  of 
typhoid  and  cholera  stools.  This  agent  is  prepared  as  follows :  To  un- 
slaked lime,  placed  in  a  jar,  as  much  water  as  it  will  absorb  is  added. 
The  unslaked  lime  is  stirred  up  with  -i  parts  of  water  to  form  the  milk  of 
lime,  and  tliis  is  mixed  intimately  with  the  discharges  until  the  mixture 
gives  a  strong  alkaline  reaction   (tested  by  litmus  paper). 

Chloride  of  lime,  to  be  effective,  must  contain  25  per  cent,  of  available 
chlorine.  Six  ounces  to  the  gallon  of  water  represents  the  standard  solu- 
tion. 

Carbolic  acid,  unless  in  combination  with  siilphuric,  and  corrosive 
sublimate  are  not  suitable  for  the  disinfection  of  stools. 

Discharges  can  also  be  disposed  of  by  burning  after  being  mixed  with 
sawdust. 

Water-closets  are  best  disinfected  by  chloride  of  lime  solution. 


CHAPTEE  VIII. 

THE  ADMINISTRATION  OF  DRUGS  TO  CHILDREN. 

A  FEW  points  concerning  the  use  of  drugs  in  children  should  be 
noted : — 

1.  Give  the  minimum  dose  of  a  drug  in  the  beginning  of  a  disease. 
3.  Administer  the  drug  in  a  palatable  form. 

3.  The  soluble  tablet  triturates  should  be  administered,  as  they  com- 
bine a  minimum  quantity  with  solubility  and  palatability. 

4.  Remember  the  idiosyncrasies  of  drugs  and  guard  against  toxic  doses 
by  watching  the  effect  of  a  drug  in  any  given  case. 

5.  In  some,  specific  diseases  such  as  diphtheria,  give  a  sufficient  quan- 
tity of  antitoxin  to  obtain  a  therapeutic  result. 

6.  Certain  drugs,  for  example,  belladonna,  calomel,  quinine,  strych- 
nia, bromoform,  and  alcohol.  ii'Jicn  cautiously  administered  can  be  given 
in  very  large  doses.  It  is  only  necessary  to  note  the  physiological  effect 
and  then  to  give  the  drug  until  its  point  of  tolerance  is  reached. 

Accuracy  in  dealing  with  poisons  is  very  important  in  children.  It 
is  surprising  to  see  the  difference  in  size  of  various  teaspoons  on  the  nuirket. 
I  advise  using  a  medicine  glass,  which  is  graduated  with  teaspoon,  etc. 


(936) 


CHAPTEE  IX. 

LOCAL  REMEDIES. 

Cold  Compresses. 

Cold  compresses  may  be  made  out  of  linen  or  cheese-cloth  folded  sev- 
eral times  and  wrung  out  in  ice-water.  If  there  is  any  abrasion  of  the 
skin,  1  part  of  glycerine  should  be  added  to  every  5  parts  of  water.  If  con- 
stant cold  is  wanted,  compresses  should  be  changed  frequently. 

Hot  Compresses  or  Fomextatioxs. 

Hot  compresses  or  fomentations  are  made  by  wringing  out  a  piece 
of  flannel  in  hot  water.  As  this  is  oftentimes  hotter  than  the  hands 
can  stand,  the  flannel  may  be  placed  in  a  towel,  two  ends  being  kept  from 
the  water  and  then  wrung  out  in  the  towel  by  twisting  the  ends.  In  apply- 
ing fomentations  they  should  not  be  hotter  than  can  be  borne  by  the  face 
of  the  mother  or  nurse.  To  retain  the  heat  they  may  be  covered  with  oil 
silk,  oil  paper,  or  oiled  muslin,  and  then  with  a  dry  tow^el.  Renew  when 
cool. 

Poultices. 

A  poultice  is  intended  to  supply  heat  for  a  greater  period  than  a 
fomentation.     It  should  not  be  more  than  one-half  inch  in  thickness. 

A  flaxseed  poultice  is  made  as  follows:  A  sufficient  quantity  of 
"nater  is  heated,  and  when  iDrought  almost  to  the  boiling  point,  the  flaxseed 
meal  should  be  added  slowly,  stirring  all*  the  while  to  avoid  lumping. 
The  meal  may  be  added  until  it  has  the  consistency  of  hot  mush, 
too  thick  to  flow.  This  may  be  spread  on  a  piece  of  linen  or  cotton 
cloth,  the  edges  turned  over  slightly  and  the  part  to  which  it  is  to  be 
applied  next  to  the  body  must  be  covered  with  an  old  handkerchief  or 
thin  piece  of  linen.  See  that  it  is  not  hot  enough  to  burn  the  skin. 
Tlie  poultice  should  1k'  larger  than  the  affected  area.  Afterward  cover 
with  oil  silk  or  paper  to  keep  out  the  air,  and  then  bandage  in  place.  This 
can  be  renewed  every  hour  or  so.  Have  everything  ready  when  the  poul- 
tice is  made,  as  it  ([iiiekly  cools  when  exposed  to  tbc  air. 

TuRi'KN"TiNE  Stupes. 

Turpentine  stupes  are  found  very  useful  in  cases  of  abdominal  pain. 
A  piece  of  flannel  is  wrung  out  in  hot  water,  the  same  as  in  a  fomentation. 

(937) 


938  MISCELLANEOUS. 

except  a  little  soap  or  oil  added  to  the  water.  A  little  turpentine  should 
then  be  sprinkled  evenly  over  the  surface  of  the  flannel,  about  30  drops  to 
each  square  foot  or  a  teaspoonful  may  be  added  to  the  water.  Apply  the 
same  as  a  fomentation. 

Mustard  Plasters. 

Mustard  plasters  for  infants  should  be  made  with  1  part  of  mustard 
to  3  or  4  parts  of  flour  or  flaxseed  meal.  Add  warm  water  and  stir  until 
of  the  proper  consistency.  Spread  thinly  on  a  cloth  and  apply  directly  to 
the  skin.    It  is  to  be  kept  on  until  the  skin  is  reddened,  not  blistered. 

Ginger  Poultice. 

Ginger  poultice  is  made  in  the  same  way  as  that  described  for  the 
making  of  mustard  plasters,  and  has  its  advantages  in  that  it  will  not 
blister. 

Caxtharidal  Collodion. 

In  using  the  cantharidal  collodion  care  should  be  exercised  to  remove 
all  moisture  and  excretions  from  the  skin  before  applying,  otherwise  tlie 
cantharidin,  l)eing  soluble  in  water,  will  not  come  into  contact  with  the 
skin.  One  of  the  most  convenient  methods  of  preparing  the  skin  for  the 
application  of  cantharidal  collodion  is  to  wash  the  jjart  with  vinegar  or 
dilute  acetic  acid. 

Venesection  (Blood  Letting). 

Local  blood  letting  is  frequently  a  valuable  therapeutic  aid,  especially 
in  meningitis  and  in  cerebral  pneumonia,  in  fact,  wherever  symptoms  of 
cerebral  hypera^mia  are  noted.  Convulsions  are  sometimes  prevented  by 
relieving  congestion  with  the  aid  of  a  few  leeches.  Baginsky  reports  the 
value  of  venesection  as  a  routine  measure  in  certain  types  of  diseases,  such 
as  continued  convulsions,  in  which  relief  can  be  afforded  by  this  means. 
The  skill  of  the  surgeon  is  necessary,  for  we  must  consider  the  possibility 
of  infection  while  opening  a  vein. 

Dry  Cupping. 

The  application  of  dry  cups  is  useful  in  marked  dyspnoea.  It  is  there- 
fore indicated  in  asthma,  broncho-pneumonia,  and  in  pulmonary  oedema, 
two  cups  may  be  applied  on  each  side  posteriorly  for  several  minutes.  If 
relief  is  afforded,  they  can  be  applied  once  every  twelve  hours. 


CHAPTEE  X. 

RECTAL  MEDICATION  IN  CHILDREN. 

When  the  stomach  is  irritable  in  young  chiklren  I  prefer  to  medicate 
per  rectum.  The  gastric  mucous  membrane  will  sometimes  show  an  in- 
tolerance for  drugs.  It  is  advisable,  especially  in  exhaustive  diseases,  such 
as  diphtheria,  typhoid  fever,  and  the  intestinal  disorders,  to  support  the 
strength  of  the  body  with  nutrition.  In  such  cases  vomiting  may  be  pro- 
voked by  the  administration  of  drugs.  Children  will  frequently  object  to 
taking  medicine,  and  it  is  painful  to  watch  the  struggle  between  mother 
and  child  while  attempting  to  force  the  medicine  into  the  infant's  mouth. 
In  such  cases,  especially  in  very  young  infants  with  whom  we  cannot  reason, 
the  rectum  should  be  chosen  as  the  proper  channel  for  the  introduction  of 
the  drug.     The  rectum  absorbs  slowly  but  surely. 

The  following  drugs  may  he  given  per  rectum  and  the  doses  gradually 
increased: — 

Aconite  may  be  given  in  suppository,  but  shows  its  action  only  in  large 
doses.  We  must  therefore  administer  it  in  repeated  small  doses  to  obtain 
its  effect.  For  example,  we  may  give  1  or  3  drops  of  the  tincture  in  a 
suppository  to  a  year-old  child. 

Belladonna  acts  as  an  excellent  sedative  in  cough,  and  exerts  a  very 
favorable  influence  on  the  muscle  liber  of  the  intestine.  We  may  use  Vs 
minim  of  extract  of  belladonna  in  twenty-four  hours,  divided  into  three 
or  four  su))})Ositories,  for  every  two  years  of  age. 

Bromides  should  be  given  in  doses  of  3  grains  for  each  year  of  life,  in 
two  suppositories;  V4  grain  if  it  is  to  be  continued.  In  severe  spasm  wc 
may  give  two  grains  for  each  year  of  life,  in  two  suppositories  raj)idly  fol- 
lowing each  other;  for  exam))le.  in  lar}iigismus  stridulus. 

Caffeine  is  usually  injected  subcutaneously.  It  may.  however,  be 
administered  in  a  suppository  with  equal  parts  of  benzoate  of  sodium. 
For  example,  one  and  one-half  grains  to  a  su])pository,  using  two  daily 
for  each  year  of  tlic  cliibrs  life. 

Digitalis. — Powdered  digitalis  is  with  difTiculty  absorl)ed  1)V  the  rec- 
tum. 'Vhc  tincture  should,  tlicrci'nrc.  be  used.  Th<^  maximum  dose  for 
each  year  of  life  i>    I  drops,  divided  iulo  Iwo  siippositoi'ics. 

Iodine  and  its  preparations  arc  exceptionally  well  borne  by  the  rectum, 
and  fully  absorbed.  Three  grains  for  each  year  of  life,  in  two  sui)posi- 
tories,  is  the  maximum  dose;  ^/^  grain  if  it  is  to  be  continued. 

(939) 


940  MISCELLANEOUS. 

Mercury  should  only  exceptionally  be  given  per  rectum,  and  then  only 
in  the  form  of  calomel,  ^/^  grain  in  a  suppository  for  each  year  of  life. 

Nux  Vomica. — One-sixth  of  a  grain  for  every  two  years,  in  three  sup- 
positories. 

Strychnine  should  only  he  given  to  children  T\\cv  10  years  of  age. 

Salicylic  Acid. — Seven  and  three-quarter  grains  for  each  year  of  life, 
in  divided  doses   (three  or  four). 

Quinine  is  best  given  in  suppositories.  The  daily  maximum  dose  is 
2  to  3  V-j  grains,  in  two  suppositories,  for  each  year  of  life, 

Antipyrine  may  be  given  in  the  same  dose  as  quinine. 

Opium. — Pulvis  opii  m;iy  be  given  in  suppositories,  in  doses  of  ^/,.,o 
grain  for  each  year  of  the  child's  age,  and  this  dose  nuiy  be  repeated  in 
severe  cases  every  two  hours. 

Toxic  symptoms  should  be  carefully  watched  for.  and  the  use  of  the 
remedy  discontinued  on  their  appearance.  These  doses  are  small  ones  and 
may  be  increased. 


CHAPTER  XL 


PRESCRIPTIONS  FOR  VARIOUS  DISEASES. 

The  following  prescriptions  have  served  the  author  and  are  in  use  at 
one  of  his  clinics  in  New  York  Citv : — 


StTMJdTEB   DiARRHCEA. 

I^  Calomel  tablets,  Vio  grain. 

One  every  two  hours  for  a  child  1  to 
•2  years  old. 

Followed  by  (next  day) : — 

I^   Bismuth  betanaphthol,  5  grains. 
Everj'  two  hours  in  water.     Or 

R  Mist,  creta,  2  ounces. 

Teaspoonful  every  two  hours.     Or 

I^  Bismuthi  subnit.,  20  grains. 
Z\listur0e  cretae  comp.,  4  drachms. 
Aquse,  q.  s.  ad  2  ounces. 
M.     Tea.spoonful  every  two  hours. 


Gastro-exteritis. 
IJ  Castor  oil. 

Teaspoonful  eveiw  two  hours  for  one 
day. 

If  diarrhoea  persists  after  flushing  the 
colon  and  rectum  and  also  washing  the 
stomach,  after  using  former  remedies: — 
IJ  Eudoxine,  5  grains. 

Every  three  hours. 

The  diet  is  most  important. 


Persistent  Vomiting. 
T^avage   (stomach  washing)   with  table 
salt  one  teaspoonful  to  quart  of   warm 
water    (100°    F.).      Then    leave   stomach 
rest  for  at  least  six  hours. 


MouTii-WAsn. 
Pulv.  acid,  boric,  solution  (1  per  cent.). 


Stom.\titis  or  ApirTii.E. 
R  Solut.  Kali  Permangan.   (1   per  cent.). 
Dilute  with  equal  paits  of  waini  water. 
Wash  three  times  a  day. 


Tonic    After    Exhaustive    Disease, 
Such     as     Pneumonia     or   Summer 
Diarrhoea. 
IJ  Ferri  pyrophos.,  1  drachm. 
Quininse  sulph.,  V2  drachm. 
Strych.  sulph.,  14  grain. 
Acid  phosph.  dil.,  2  drachms. 
Aquse,  q.  s.  ad  4  ounces. 
M.     Teaspoonful  three  times  a  day. 


Tonic  and  Restorative. 
IJ  Ferri  et  quiniae  citrat.,  V2  drachm. 
Syrup  hypophos.  comp.,  4  drachms. 
Aquae,  q.  s.  ad  2  ounces. 
M.     Teaspoonful  after  each  meal. 


Tonic  for  Chorea, 
IJ   Liq.  potass,  arsenitis,  1/2  drachm. 
Ferri  et  amnion,  citrat..  1  dracliiii. 
Aquse,  q.  s.  ad  2  ounces. 
M.      Teaspoonful    three   times   a    day. 
Increase  ffraduallv. 


Pertussis. 
R   Bromoform   (Merck),  1  drachm. 
Tinct.  cardamom  comp.,  1  drachm. 
M.  D.  S.:      Five  drops  in  water  three 
times  a  day  for  a  child  1  year  old. 

Add  1  drop  for  every  two  years,  thus: 
0  diops  for  l)aby  3  years  old 
7  drops  for  baby  5  years  old 

Or:  — 
R  Fl.  ext.  belladonna,  10  drops. 

^fist.  glycerrhiz.  comp.,  q.  s.  ad.  2  ounces. 

AT.  D.  S.:  Teaspoonful  every  two 
hours  for  a  child  2  to  4  years  old; 
younger  children  V2  the  dose. 

(941) 


942 


MISCELLANEOl-S. 


Or:  — 

Apply  ling,  belladonna  over  surface  of 
chest  every  second  night. 


Capii.i.ahy  Bkonchiti.s. 

When  expectoration  is  viscid:  — 
H  Amnion,  carbonat.,  10  grains. 
Syr.  senega,  4  drachms. 
Syr.  prun.  virg.,  U  drachms. 
Aqiue  camph.,  q.  s.  ad  2  ounces. 

M.  i).  S. :     Teaspooiiful  cxery  two  lio\irs 
with  water. 


Acute  Catarkhai.  Buoxciiitis. 

R  Amnion,  muriat.,  1.3  grains. 
Animon.  broiiii(l._,  20  grains. 
Syr.  liquorit,  (i  drachms. 
Tinct.  opii  camph.,  2  drachms. 
Aqiup,  (J.  s.  ad  2  ounces. 

M.  D.  S. :      One-half  teaspoonful  every 
two  hours. 


Pleurisy. 


(Cough  with  pain,  on  Ineathing.) 
I^   Pulv.  Doveii,  10  grains. 

Pulv.  ext.  liquorit,  20  grains. 
Sacch.  albi,  .30  grains. 

M.  ft.  chart,  no.  20. 
M.    D.    S.:       One    powder   every   three 
hours. 


Tubercular  Cough. 

IJ  Creosote  carbonate. 

Five  drops  in  milk,  soup  or  broth  tliree 
times  a  day,  for  a  child  2  years  old. 

Persistent    Diauriicea,    with    Tuber- 

CT'LAR     SyMI'TOMS. 

IJ  Guiacol  carhonate,  .3  to  5  grains. 
For  a  child  1  vcar  old. 


Enterocolitis. 

IJ  Tinct.  kino,  20  minims. 

Misturfe  cretae  comp.,  1  drachm. 
Aquir,  q.  s.  ad  2  ounces. 

M.     Teaspoonful  every  three  hours. 


Colitis,  with  Pain. 

R   Tinct.  opii  camjjh.,  10  minims. 
Bismuthi  subnit.,  2  grains. 
Aquas  calcis,  i[.  s.  ad  4  drachms. 

yi.     Teaspoonful  every  two  hours. 


Atonic  Dy'spepsia,  with  Constipa- 
tion. 

R  Pulv.  rad.  ipecacuanhae,  1  grain. 
Pulv.  rad.  rhei,  10  gi-ains. 
Sodii  bicarbonat.,  Va  drachm. 
Tinct.  nucis  vomicae,  1.5  drops. 
Aquae,  q.  s.  ad  2  ounces. 

M.      Teasjioonful  before  each  fee.ling. 


To  Abort  Acute  Tonsillitis. 
IJ  Creosote,  8  drops. 

Tinct.  myrrh,  2  ounces. 
Glycerine,  2  ounces. 
Aquae,  4  ounces. 
]\I.  D.  8.:      Gargle  everv  hour. 


Acute  Tonsillitis. 

R  Tinct.  aconit.  rad. 

One  drop  every  hour  for  six  doses  to  a 
child  1  to  5  years  old. 


Infantile  Eczema. 

(Dry,  vesicular  and  papular.) 
Leistikow  recommends :  — 
IJ  Zinci  oxidi,  1  drachm. 
Amyli,  1  drachm. 
Adipis  lanee,  1  drachm. 
Petrolati,  21/2  drachms. 
Hydrar.  oxid.  flav.,  4  t(,'  8  grains. 
M.  ft.  pasta. 

Kistler  employs  the  following  oint- 
ment to  relieve  the  itching  of  infantile 
eczema :  — 

R  Salicylic  acid,  l.")  grains. 

Bisnuith  subnitrat.,  4  drachms. 

Powdered  starch,  1  '/o  drachms. 

Cold  cream,  2  oimces. 
Calomel,  in  the  dose  of  1  or  2  grains, 
is  indicated  from  one  to   three  times  a 
week,  to  aid  in  the  elimination  of  patho- 
logic products. 


PRESCUIPTIONS. 


943 


Stimulating  Expectorant  Useful  in 
Bronchitis. 

IJ  Amnion,  carbonat.j  Va  ilraolnii. 
Tinct.  senegffi,  20  drops. 
Tinct.  opii  oamphorat.,  3  draclun.s. 
Syr.  tolutanj  5  drachms. 
Aquse,  q.  s.  ad  G  ounces. 

^I.       Teaspoonful    every    two    or    four 
liours.     Diluted  with  water. 


Tuberculosis. 

R   Creosote  carbonate,  30  drops. 
Spiritus  frumenti,  4  drachms. 
Glycerinse,  4  drachms. 
AquiP,  q.  s.   ad   4  ounces. 

]\r.      Teaspoonful  every  four  liours  or 
oftener. 


Vaginitis. 
R  Alum,  powdered,  1  ounce. 

Or:  — 
I^  Zinc  sulphate,   1   ounce. 

Or:  — 
^.   Borax,  1  ounce. 

Sig. :  A  tablespoonful  to  a  quart  of 
water  to  be  used  as  a  vaginal  injection 
three  or  four  times  a  day.  Apply  a  sterile 
pad  of  cheese-cloth.  A  fresh  pad  to  be 
applied  after  each  irrigation. 


Fever  Mixture. 

R  Tr.  aconite  rad..  10  drops. 
Spir.  mindererus,  2  ounces. 

M.     Sig.:      One-half  teaspoonful  every 
liour  for  a  child  2  to  4  vears  old. 


HYrODEimiC    j\rEDICATION. 

When  immediate  relief  is  required,  hypodermic  medication  shoukl  be 
given.  The  rapid  action  of  liypodermic  medication  is  best  shown  in  giving 
a  dose  of  apomorphia  hypodermically  for  the  relief  of  spasmodic  croup. 


CHAPTEE  XII. 


Remedies  Most  Frequently  Administered, 

For  hypodermic  use  the  dose  should  be  half  that  used  by  the  mouth. 
For  use  hy  rectum  the  dose  should  be  twice  that  used  by  the  mouth. 

Dose  for  Children. — Dr.  Young's  rule:  Add  12  to  the  age,  and  divide 
the  age  by  the  result. 

Example. — For  a  child  2  vears  old,    1^2+2_i  The  dose  should  lie 

V^  that  for  an  adult. 

In  giving  powerful  medicines  and  opium  still  smaller  doses  must  be 
used  for  children. 

TABLE  OF  DOSES. 
Owing  to  the  toxic  effect,  drugs  marked  "*"  must  be  given  with  greater  caution. 


Remedies. 


*Acid,    arsenious 

benzoic    

boric    

camplioric   (to  check  niglit-sweats)  .  .  .  . 

*carbolic   

gallic   

gallic   ( in  albuminuria ) 

hydrobromic,  diluted    

hydrochloric,  diluted    

*hydroeyanic,  diluted 

nitric,  diluted    

nitrohydrochloric,  diluted 

phosphoric,  diluted 

salicylic 

sulphuric,  aromatic    

sulphuric,    diluted 

sulphurous    

tannic    

*Aconitina    (white  crystals) 

*Adonidin    (heart-tonic) 

Aloes   

Aloinuni    

Ammonii  benzoas   

bromiduTii    

carbonas    

chloridnm    

iodiduin     

valerianas 

•Amjd  nitris   (inhaled  or  internally) 

Antimonii  et  potassii  tartras   (diaphoretic) 

et  potassii  tartras   (emetic) 

oxysulphuret    

Antipyrin    

(944) 


Grains  or  Minims 

FOR  Child 
Three  Years  Old. 


003  to  0.01 
to  3 

to  2 
to  6 

1  to  0.3 

0  to  3 
to  12 
to  12 
to  4 

4  to  1.2 
to  4 

to  4 

to  6 

to  4 

to  3 

to  6 

to  12 
4  to  2 
0007  to  0.001 

02  to  0.065 
4  to  1 

025  to  0.6 

to  4 

to  6 
G  to  2 

to  0 
4  to  3 
4  to  3 
4  to  1 

01  to  0.02 

2  to  0.4 
1  to  0.4 
4  to  3 


TABLE  OF  DOSES. 


945 


Remedies. 


Apomorphine  hydrochloride   

Argenti  nitras   

*Arsenii  iodidum    

*bromidum   

*Atropinse  sulphas   

*Auri  et  sodii  chloridum 

Bismuthi  subnitras 

salicylas    

*Bromoformum    ( in  whooping-oough,  etc. ) 

Caffeine 

Calcii  chloridum  hydratum 

Calcii   lacto-phosphas 

Camphora   

monobromata   

Cerii  oxalas   

Chinoidinum    

Chloral 

Chloralamidum    (hypnotic)    

Chloroformum    

Chrysarobinum   (eczema)    

Cinchonidina,  and  its  salts 

Cocaina   (locally,  14  per  cent,  solution),  internally.  .  .  . 

Codeina 

•Colchicine   

Confectio  sennse 

*Creolin   ( locally,  %  to  2  per  cent,  solution ) ,  internally 

Creosotum 

Croton-chloral    

Cupri  acetas 

sulphas    ( emetic )    

*Digitalinum   

*Digitalis    

*Duboisina,  and  salts 

*Elaterinum   ( U.  S.  P.,  1880 ) 

Emetina,  and  salts   (emetic) 

Ergota  

Ergotinum    

*Erythrophloeina   (local  anaesthetic,  heart-tonic) . 

*Eserina,  and  its  salts 

Ethyl  chloride   (local  anaesthetic) 

Fel  bovis  purificatum 

Ferri  arsenas 

bromidum    

carbonas  saccharatus   

et  ammonii  citras 

et  ammonii  tartras 

et  potassi  tartras   

et  strvchninre  citras   

hypophosphis    

iodidum  saccharatum 

lactas     

oxidum  hydratum  cum  magnesia 

(antidote  to  ar.senic) 

pyrophosphas  

subcarbonas  

60 


Grains  or  Minims 

FOR  Child 
Three  Years  Old. 


0.0065  to  0.02 

0.035  to  0.1 

0.003  to  0.02 

0.003  to  0.012 

0.0015  to  0.006 

0.006  to  0.025 

1  to  12 

1  to  4 

1  to  2 

0.2  to  1 

1  to  4 

1  to  2 

0.6  to  2 

0.4  to  1 

0.2  to  2 

0.6  to  6 

0.6  to  4 

3  to  12 

0.2  to  6 

0.035  to  0.6 

1  to  6 

0.012  to  0.1 

0.012  to  0.4 

0.002  to  0.004 

12  to  24 

0.1  to  1 

0.1  gradually 

increased 
0.2  to  1 
0.025  to  0.1 
0.012  to  0.05 
0.003  to  0.006 
0.025  to  0.4 
0.0015  to  0.0033 
0.0035  to  0.016 
0.025  to  0.05 
3  to  12 
0.4  to  1.6 
0.012  to  0.025 
0.003  to  0.01 

1  to  2 

0.01  to  0.035 
0.2  to  1 
0.4  to  3 
1  to  2 

1  to  3 

2  to  6 
0.2  to  1 
1  to  2 
0.4  to  1 


0.2  to  0.6 

iZ  0.8  to  f3  1.6 

frequently 
0.2  to  1 
1  to  6 


946 


MISCELLANEOUS. 


Remkdies. 


Ferri   sulphas    

sulphas  exsiceatus    

valeiianas 

FeiTuiu  dialys   

reduetuin    

Gaulthoria,  oil  of 

Guaiaeol    (constituent  of  creosote) 

Guaiacol  carbonas  vel  benzoas 

liomatropiniB    hydiobromidiun     (mydriatic,    locallj^    0.2    per 

cent,  to  4  per  cent. )    

"Hydrargj'ri  chloridnm  corrosivuni    

*cliloridum  mite    

*Hydrar<iryri  iodidnm  rubrum    

iodidum  vir 

subsulphas  flava    (as  emetic) 

Hydrargjaiun  cum  creta   

Hydrastine   

Hydrogenii      dioxidum    (10-volume  solution),   locally,    (25   to 

100  per  cent. ) ,  antiseptic 

*Hyoscina;  hydrobromas    

*Hyoscyamina^  sulphas    

Ichthyol   (locally,  10  to  50  per  cent.),  internally 

Infusum  digitalis    

iodoformiun    

lodol    

ledum    

Ipecacuanha    (expectorant)    

"  ( emetic )    

Jalapa  

Liq.  ammonii  acetatis   

acidi  arseniosi   "]  ] 

arsenii  bromidi   |        Commencing  doses 

arseni  et  hydrargyri  iodidi    [  to  be 

potassii  arsenitis inci'eased  cautiously 

sodii  arseniatis   J 

ferri  chloridi    

ferri  dialys  

potassii   citratis    

Lithii  benzoas   

bromidum 

carbonas    

citras 

salicylas    

Lupulinum   

Magnesii  carbonas 

citras,  gran •. 

sulphas    

Mangani  oxidum  niger   

Methylene  Itlue  with  powdered  nutmeg   (malarial  fevers)  . 
Mistura  chloroformi 

ferri  et  ammonii  acetatis 

glyeyrrhiza;  composita 

potassi  citras 

rliei  et  sodiT; 

Morphina.  and  its  salts 

Morrhuol  (derivative  of  cod  liver-oil ) 

Moschus    

Naphtliol     

*Nitroglycerinum  (trinitrin),  i/.  per  cent,  solution 


Grains  OR  Minims 

FOB  Child 
Thrkk  Years  Olu. 


0.2  to  0.6 
0.1  to  0.5 
0.2  to  0.6 
0.2  to  3 
0.2  to  1 
O.G  to  2 
0.05  to  1 
0.0G5  to  2 

0.035  to  0.5 

0.003  to  0.02 

0.012  to  2 

0.004  to  0.02 

0.035  to  0.2 
0.4  to  1 
0.0  to  1.6 
0.0  to  1 

6  to  24 

0.001  to  0.0035 

0.001  to  0.003 

O.G  to  1 

f3  0.2  to  fS  0.8 

0.2  to  1 

0.035  to  0.1 

0.02  to  0.05 

0.035  to  0.2 

3  to  6 

3  to  0 

fS  0.4  to  fS  1.6 


0.2  to  1 


0.4  to  2 

2  to  6 

f3  0.4  to  fSO.S 

1  to  4 

1  to  4 

0.4  to  2 

1  to  4 

1  to  6 

1  to  6 

3  to  12 

3  0.4  to  3  1.6 

2  to  0 
0.2  to   1 
0.2  to  1 

f3  0.2  to  f31.6 
f3  0.2  to  f3  0.8 
f3  0.2  to  f3  0.8 
f3  0.8  to  f3  3.2 
f3  0.8  to  f3  l.G 
0.0012  to  O.OOG 
0.0  to  12 
0.4  to  3 
0.4  to  1 
jltt.  0.5  increased 


TABLE  OF  DOSES. 


947 


Remedies. 


Oleoresina  aspidii    (filix  mas) 

Opium   ( 14  per  cent,  morphine) 

Phenocoll   liydrochloride    

*Phosphorus     

*Physostigmin2e  sulphas   

*Picrotoxinum   

*Pilocarpina,  and  salts   (cautiously) 

Piperazin    

Plumbi  acetas   

Potassii  acetas  

bicarbonas    

Potassi  bromidum 

bitartras    

chloras  

cyanidum    

iodidum 

nitras  

permanganas    

tartras    

Pulvis  antimonialis    

glycj'rrhizae  compositus 

ipecacuanhae  et  opii 

jalapae  compositus    

rhei  compositus 

Resina  copaibse   

euonymi    

guaiaei    

jalapae    

podophylli 

scammonii 

Resorcin    

Rheum 

Saccharine   (substitute  for  sugar) 

Salicinum    

Salipyrin    (antipyretic,  antineuralgic )  .... 

Salol    

Salophen    (r.ntipyretic,  antirheumatic).... 

Santonium    

Senna  

*Sodii  arsenas 

benzoas    

boras    ( in  epilepsy) 

bromidum   

chloras     

hyposulphis    

iodidum   

plios])has   

sal  icy  las    

'Sparteine  sul])1ias  (cardiant  and  diuretic) 
Spiritiis  rflhoris  nitrosi   

aetlieris  comjuisitus   

amnion  ire  aroma  ticus 

camphora;   

chloroformi 

Strontii  lactas  vrl  bromidum  vel  iodidum. 

*Stryclinina,  and  salts 

Sulphonal   (best  in  hot  mint-water) 


Grains  or  Minims 

FOR  Child 
Three  Yeabs  Old. 

1  to  3 
0.0:^5  to  0.4 
1.6  to  3 
0.0015  to  0.004 
0.001.5  to  0.004 
0.0016  to  0.004 
0.003  to  0.001 
3    (daily) 
0.1  to  0.6 
3  to  12 
1.6  to  12 
1.6  to  12 
0.2  to  0.4 
1.6  to  6 
0.01  to  0.025 
0.4  to  6 
0.4  to  3 
0.1  to  1 
3  0.2  to  3  1.0 
0.2  to  0.6 
6  to  12 

1  to  3 

2  to  12 
1  to  12 
0.4  to  2 
0.4  to  1 
1  to  4 
0.4  to  1 
0.016  to  0.1 
0.4  to  2 
0.4  to  1 

0.4  to  6 
0.1  to  1 
1  to  0 
1.6  to  3 
0.4  to  2 

3  to  4 
0.05  to  1 
1.6  to  36 
0.003  to  0.02 
1  to  3 

1  to  6 

1  to  6 

0.4  to  1 

1  to  4 

0.4  to  6 

0.4  to  24 

1  to  6 

0.012  to  0.8 

3  to  24 

3  to  24 

3  to  12 

1  to  0 

3  to  12 

3  to   12 

0.003  to  0.016 

1   to  4 


948 


MISCELLANEOUS. 


Remedies. 


Sulphur  

Syr.  ferri  bromidi 

ferri  iodidi 

scillae  compositus 

senegiie   

seniiiE 

Terebene   

Terpin  liydrate   (tonic  expectorant) 

Theobrominae  et  sodii  salicylas   (diuretic) 

Tliymol 

*Tinctura  aconiti   

aloes  

asafcBtidae    

belladonnge    

cannabis   indicae    

capsici   

cimicifugiie 

cinchonae  composita   

colchici  seminis 

conii 

*digitalis    

ferri  cliloridi   

gelsemii 

guaiaci  ammoniata 

hydrastis    

hyoscyami 

*ignatiae    

iodi  compositus   

kino   

lobelise   

moschi  

nucis  vomicae   

*opii    

opii  camphorata   

*physostigmatis 

stranionii    

strophantlii   (cardiani  and  diuretic) 

Valerianae   ammoniata    

veratri  viridis   

•Trional   (hypnotic)   

Trituratio  elaterini    ( 10  per  cent.) 

Vinum  antimonii  (expectorant  and  alterative) 
(emetic)     

colchici    

ergotae   

ipecacuanhae    (expectorant)     

(emetic)    

opii    

Zinci  acetas   

l)ron)idum   

iodidum   

oxidum    

phosphidum 

sulphas    (emetic)    

valerianas   


Grains  or  Minims 

FOR  Child 
Three  Years  Old. 


3  0.1  to  3  0.S 

1  to  12 

1  to  6 

1  to  6 

f3  0.2  to  f3  0.4 

f3  0.2  to  f3  1.6 

1  to  3 

0.4  to  1 

1  to  6 

0.2  to  1 

0.1  to  1 

3  to  12 

6  to  12 

0.4  to  3 

1  to  4 

1.6  to  3 

6  to  12 

3  to  24 

1  to  4 

1  to  6 
0.6  to  3 

2  to  6 
0.4  to  3 
6  to  12 
6  to  24 
1  to  G 

1  to  0 
1.4  to  3 

3  to  24 
1  to  6 
3  to  12 
1  to  3 
0.4  to  3 
1  to  48 
1  to  3 

1  to  3 
0.2  to  2 

2  to  24 
0.6  to  2 

3  to  12 
0.025  to  0.2 
0.2  to  1.6 

6  to   15 

1   to  3 

f3  0.2  to  f3  0.6 

1  to  3 

f3  0.4  to  f3  1.2 

1  to  3 

0.1  to  0.4 

0.1  to  1 

0.1  to  0.6 

0.2  to  1 

0.02  to  0.035 

3  to  6 

0.1  to  1 


IISrDEX. 


Abdomen,  260;  in  ascites,  392;  tapping,  394; 
in  cretinism,  760;  in  Henocti's  purpura, 
750;  in  intussusception,  322;  in  peri- 
tonitis, 388;  in  pseudo-leultsemic  anaemia, 
737;  in  rachitis,  342;  in  typlioid,  694;  in 
dislocation  of  the  hips,  900. 
Abdominal    band,   20. 

in  gastroptosis,  257;   in  pertussis,   496. 
Abnormal  growths,  884. 
Abnormalities,    congenital,   53. 

of  air  passages,  56. 
Abortive  pneumonia,  499. 
Abscess,  alveolar,  233. 
cerebral,  843;  in  measles,  639. 
complicating    Pott's    disease,    893;    vaccin.i- 

tion,  686. 
due  to  hernia,    894;   sacral   or  iliac   disease, 

894. 
hepatic,  caused  by  worms,  328. 
in  perinephritis,  409,   410;   pyelitis,  412. 
ischio-rectal,  332. 

of  brain,   843;    diagnosis,    844;    etiology,   843; 
pathology,     843;     prognosis,    845;     symp- 
toms,  844;   treatment,  845;   surgical,   845; 
of  cervical   region,    894;    of   inguinal   re- 
gion,  894;   of  loin,   894;  of  spine,  894;   of 
thoracic  region,  894. 
peritonsillar,  433;  resembling  diphtheria,  558. 
retro-cesophageal,  234. 
retro-pharyngeal,    442;    complicating    scarlet 

fever,  655. 
subphrenic,  385. 
Abscesses,  in  erysipelas,  703;   in  typhoid,  698. 
multiple,    complicating   cerebro-spinal   men- 
ingitis, 824;  scarlet  fever,  600. 
renal,  in  urinary  passages,  412. 
of  thymus,   773. 
Acetonuria,  415;    in   diabetes  me'litus,  419. 
Acid,   carbolic,    as  disinfectant,   935. 
hydrochloric,  in  gastric  contents,  237,  915. 
laccic,  in  gastric  contents,  237,  915. 
Acute  fatty  degeneration  of  the  new-born,  50. 
Acute  meningitis,  824. 
Acute  milk  infection,  302. 
Addison's  disease,  774. 

Additional   foods  during  nursing  period,   76. 
Adenitis,    acute,    754;    pathology,    754;    prog- 
nosis,   754;    symptoms,     754;     treatment, 
754;   abortive,   754;   surgical,  754. 
chronic,   755,   diagnosis,   755;    pathology,   755; 

symptoms,  755;  treatment,  755. 
tubercular,  755;  diagnosis,  756;  from  Hodg- 
kin's  disease,  757;  from  syphilis,  756; 
pathology,  755;  symptoms,  755;  treat- 
ment, 757;  surgical,  757. 
Adenoid  vegetations,  438;'  diagnosis,  439; 
pathology,    438;    prognosis,    440;    symp- 


toms,    438;     bedwetting,     439;     deafness, 
439;     treatment,     441;     anaesthetic,     441; 
operation,   441;   heemorrhage  after,   442. 
a  point  of  entrance  of  tubercle  bacilli,  518. 
causing  deafness,  435;  enuresis,  423. 
congenital,  55. 
face,   439. 

method  of  examining  for,  439,  440. 
Adhesia  linguae,  55. 

Adherent  prepuce,   397;   treatment,  397. 
Adhesions,    in   pleurisy,    463;    in    chronic    em- 
pyema, 470. 
Administration  of  drugs,  936. 
Adrenal  glands,   diseases  of,  774. 
Adulteration  of  milk,  912  (see  also  Milk  Pre- 
servatives,   112). 
Ague  (see  Malarial  Fever),  706. 
Airing,   out  of  doors,  20. 
Air  passages,   abnormalities  of,   56. 
Alalia  idiopathica,   845. 

Albumin,  concentrated  preparations  of,   205. 
in  milk,  effect  of  heat  on,  165. 
in  urine,  918;  test  for,  921. 
transformation  of,  by  gastric  juice,  238. 
water,  905. 
Albuminoids  in  cows'  milk,  125. 
Albuminuria,    918;    in   malarial    fever,    714;    in 
measles,  633;  in  nephritis,  406,  919. 
lordotic,  416. 
orthostatic,  416. 

transient,  in  scarlet  fever,  656. 
Albumoscope,  922. 
Alcohol,  content  in  liquid  foods,  208. 

Internally,  214;   abuse  of,  277. 
Almond  milk,  905. 

Alveolar   abscess.    233;    symptoms,   233;    treat- 
ment, 233. 
arch,  in  adenoid  vegetations,  438. 
Amaurotic  family  idiocy,  849. 
Amoebic  dysentery,  281. 

Amyloid   degeneration,   in    diphtheria,   919;    in 
malaria,  919;   in  rachitis,  919;   in  scarla- 
tina,   919;    in    syphilis,    919;    in    tubercu- 
losis, 919. 
of  the  liver,  383. 
Anaemia,    733;    associated   with    masturbation, 
796. 
acquired,   733. 
congenital,  733. 
following     diphtheria,     561;     pertussis,     488; 

scarlet  fever,  661. 
in  Addison's  disease,  774. 
infantum   pseudo-leuktemica,   736. 
pernicious,  734. 
pretubercular,   5S0. 
pseudo-leuksemic,  736. 
secondary,  734. 


(949) 


950 


INDEX. 


Ansemia  (concluded). 

splenic,  733. 
Anaemic  murmurs,  367. 
Analyses    of    cows'    milk,    99,    100;    woman's 

milk,  67,  120. 
Anaesthesia,  930. 
intra-spinal,  932. 

local,  by  injection  of  sterile  water,  932. 
partial,   in  multiple  neuritis,  794. 
Anaesthetic,  chloroform,  930;  ether,  931;  ethyl- 
chloride,  931;  nitrous  oxide,  930. 
in  adenoid  operation,  4-Jl;  in  empyema,  109; 
in  tonsillotomy,  136. 
Anasarca,     general,     in     leukaemia,     736;     in 
nephritis  complicating  scarlet  fever,  666; 
in     post-siarlatiual     nephritis,     059;     in 
tuberculosis  of  the  lung,  53S. 
Angeioma,  53,  8S8. 
Angina,   pseudo-membranosa  in  scarlet  fever, 

652;  scarlatina  membranosa,  653. 
Ani,  prolapsus,  333. 
Ankle,   oedema  of,  in  chlorosis,  73S. 
Ankle-joint  and  tarsus,   diseases  of,  902. 

in  rachitis,  342. 
Anorexia,     in     acute     tuberculosis,     530;      in 
measles,  630;  in  meningitis,  827;  in  rheu- 
matism, 741,  in  rubella,  623. 
Antibacterial  action  of  the  blood,  730. 
Anticolic  nipple,  158. 
Antimeningitis  serum,  831. 

Antipyretics,    in    broncho-pneumonia,    460;    in 

cerebral    pneumonia,    511;    in    influenza, 

485;  in  scarlet  fever,  672;  in  typhoid,  699. 

Antistreptococcus    serum,    in    erysipelas,    703, 

705;   in  scarlet  fever,  668. 
Antitoxin,    diphtheria,    570;    in    treatment    of 
meningitis,  832. 
eliminated  by  woman's  milk,   69. 
in  tetanus,  801;  in  typhoid,  699. 
rashes,  555. 

streptococcus,    in    treatment    of    erysipelas, 
703,  705;  of  scarlet  fever,  668. 
Anus,  absence  of,  59. 
atresia  of,  59. 

condylomata  of,   in  syphilis,  720. 
congenital  narrowing  of,  59. 
fissure  of,  331. 
Aorta,  367;  area  of  murmur,  367. 
Aortic  bruit,  368;  from  aneurism,  368. 
systolic  murmur,  368. 

valves,  in  diastolic  murmurs,  367,  cusps  in, 
368. 
Aphasia,  complicating  cerebral  paralysis,  836; 
diphtheria,    559;    pertussis,   489;    typhoid, 
698. 
following  pertussis,  489. 
Aphonia,  due  to  paralysis,  4. 
in  hereditary  ataxy,  809. 
spastica,  intubation  in,  593. 
Aphtha-,  Bednar's,  225. 
Apoplexy,  in  pertussis,  489. 
Appendicitis,    315;    bacteriology,    315;    causes, 
316;  course  and  prognosis,  318;   differen- 
tial    diagnosis,     317;     from     abscess    of 


ovary,   31S;   from  colic,   318;   from  intus- 
susception,   318;    from   hip-joint   disease, 
318;  symptoms  and  diagnosis,  316:  treat- 
ment, 319;  when  to  operate,  319. 
catarrhal,  316. 

false   (see  pseudo-appendicitis),  319. 
gangrenous,  316. 
mild  forms,  316. 
ulcerative,  316. 
Appendicular  lithiasis,  316. 
Appendix,   vermiform,   location   of,   261. 
Appetite,  abnormal,  254. 
in   gastroptosis,   255. 
loss  of,  due  to  catarrh,  429. 
Arm  in  birth  palsy,  41. 
Arnold  steam  sterilizer,  164. 
Arthritis,  903;  bacteriology,  903;  diagnosis  and 
differential  diagnosis,  904;  from  rheuma- 
tism,    904;      from     scarlet     fever,     904; 
etiology,   903;   prognosis,  904;   symptoms, 
904;   treatment,  904. 
following  empyema,  903;  measles,  903;  scar- 
let fever,  903;   traumatism,  903. 
Arthrogryposis   (see  Tetany),  798. 
Articular  rheumatism,  742. 
Artificial   feeding   (see   Bottle  or  Hand  Feed- 

.  ing),  139. 
Ascaris  lumbricoides,  328. 
Ascites,     392;     causes,     393;     diagnosis,     393; 
etiology,  393;   pathology,  393;   symptoms, 
393;     treatment,     393;     tapping     the    ab- 
domen, 394. 
due  to  peritonitis,  393. 
Asphyxia  during  intubation,  591. 
in  diphtheria,   561;   in  retro-pharyngeal   ab- 
scess,  443. 
neonatorum,  42;  causes,  42;  treatment,  43. 
Aspiration  (see  Lumbar  Puncture), 
in    ascites,    394;    In    encephalocele,    817;    in 
hydrocephalus,    816;    in    nephritis,    com- 
plicating scarlet  fever,  666. 
of  chest   in    pleurisy    with   effusion,    465;    of 
pericardium,  377. 
Asthma,   bronchial,  455. 
dyspeptic,   259. 
thymic,  773. 
Ataxia,  hereditary,  808. 

Atelectasis      pulmonum,      complicating      per- 
tussis, 489. 
in    bronchitis,    453;    in    diphtheria,    580;    in 

premature  infants,  31. 
differentiated  from  pneumonia,  509. 
Athetosis  in  cerebral  paralysis,  836. 
Athrepsia  infantum,  356;  etiology,  356;  patho- 
logy,   357;     prognosis    and    course,    358; 
symptoms,  357;  treatment,  359. 
fatty  livers  in,  357. 
feeding  in,   359;   buttermilk,   187. 
tetany  in,   798. 
Atomizer,  426;  oil,  445;  steam,  446. 
Atony,  general,  in  gastroptosis,  255. 
Atresia  ani,  59. 

Atrophy,   infantile  (see  Athrepsia),  356;  urine 
in,  918. 


INDEX. 


951 


Atrophy  (concluded), 
in  acute  myelitis,   806;   in  multiple  neuritis, 

794. 
in  pseudohypertrophic  paralysis,  842. 
Aura  of  epilepsy,  803;  of  hysteria,  791. 
Auscultation,    in    asthma,    450;    in    bronchitis, 
453;   acute  catarrhal,   450;   capillary,   450; 
in    emphysema,    450;    in    fluid   or    air    in 
pleural    sac,    450;    in   pleurisy,    450;    sub- 
acute, 450;   in  pneumonia,  450;   in  tuber- 
culosis, 451. 
of  anterior  fontanel,  775. 
Auto-intoxication,  322. 

Babeock's  milk  test,   117. 
Babinski   reflex,  779,   826. 
in     hereditary     ataxia,     809;     in     tubercular 
meningitis,  822. 
Bacillary  diphtheria  of  the  colon,  281. 
Bacillus  of  diphtheria,  539;   of  Eberth,   in  ty- 
phoid,   689,    690;     of    influenza,     479;     in 
bronchitis,  452;  of  Pfeiffer,  479. 
Klebs-Loeffler,   539,  541;   stain   for,   929. 
pyocyaneus,  in  bronchitis,  452. 
Shiga,  in  dysentery,  283. 
tubercle,  519;   stain  for,   in  sputum,   9''.S. 
typhoid,  690. 

Vincent's,   in  nlcero-membran,ous  tonsillitis, 
432. 
Backache   in    lateral    curvature   of   the  spine, 

897. 
Backhaus's  milk,   190. 
Back-knee  in  rachitis,  355. 
Backwardness,    3;    differentiated   from   idiocy, 
846. 
in  speaking,   845. 
Bacteria,   action  of  saliva  on,  237. 
in    bronchitis,    452;    in    broncho-pneumonia, 
457;    in   cows'    milk,   63,    113;    in   cystitis, 
421;  in  empyema,  467;  in  erysipelas,  702; 
in   follicular  tonsillitis,   432:   in  measles, 
628;    in    perinephritis,    409;    in    pertussis, 
487;   in   vaginitis,   400;   in  woman's   milk, 
62. 
influence  of  gastric  juice  on,  237. 
of  the  itnestincs,  266. 
Bacteriological  mcmcranda,  928. 
stain  for  diplococcus  pneumonia;,  929;  gono- 
coocus,  929;   Klebs-Loeffler  bacillus,   929; 
meningococcus,  929;   streptococcus,  929. 
Bacterium  coli  commune,  266;  biological  char- 
acters,    267;     morphology,     266;     patho- 
genesis, 268. 
in  broncho-pneumonia,  457;  in  cystitis,  421. 
Bacterium     lactis    aerogenes,    274;    biological 
characters,   274;  morphology,  274;  patho- 
genesis, 275. 
Baginsky   tonsillotome,   436. 
Baldness     of     occiput,     in     rachitis,     346;     in 

scurvy,  339. 
Band,   abdominal,   20;   in  gastroptosis,   2.57;    in 

pertussis,    496. 
Barley  jelly,  148;   water,  147. 
Barlow's  disease,  335. 


Basedow's  disease  (see  Exophthalmic  Goiter), 

772. 
Basilar  meningitis   (see  Meningitis),  819. 
Basham's  mixture,  667. 
Bath,  at  birth,  17;  temperature  of,  18. 
bichloride,  in  syphilis,   725. 
cold,    sponge,    23;    spray,    in    hysteria,    793; 
tub,    in    typhoid,    699,   732;    hot   air,    666; 
hot   and   cold,    in   asphyxia   neonatorum, 
44. 
hot,  as  a  diaphoretic,  665. 
in  diphtheria,  570;  in  hysteria,  793;  in  rheu- 
matism, 745;  in  syphilis,  725;  in  typhoid, 
699,  732. 
oatmeal,  18. 

sulphur,   in  rheumatism,   745. 
thermometer,   18. 
Bednar's  aphthfe,    225. 

Bed-wetting,    a    symptom    of    phimosis,    397; 
caused  by  presence  of  adenoids,  423,  439. 
Beef-juice,  905. 
Bell's  paralysis,  842. 
Bicarbonate  of  soda  solution,   130. 
Biedert's  cream,  134;  how  to  make,  135. 
Bifid  tongue,  232. 

uvula,  2.32. 
Bile,   381. 

Bile-ducts,   congenital  obliteration  of,  35;  eti- 
ology,  35;   pathology,   35;   symptoms,    36. 
Bilious  attack    (see  Acute  Intestinal   Indiges- 
tion), 299. 
Birth  palsy,  40. 

Bladder,  413;   extroversion  of,  413. 
location  of,  413. 
proper  training  of,  22. 
stone  in,  420. 
washing,  420,  421. 
Bleeders  (see  Haemophilia),  751. 
Blepharitis,  866. 

Blindness  following  meningitis,  831. 
Blisters  (see  Burns),  881. 
Blood,  726;   antibacterial  action  of,  730. 
at   birth,    726;    corpuscles,    red,    726;    white, 
727;   size  of,  727;   haemoglobin,   727;   spe- 
cific gravity,  727. 
circulation   of,   during   foetal   period,   361 ;    in 

early  life,  .362. 
crisis,  in  pneumonia,  508. 
erythroblasts,   728. 
examination    of,    711;    to   prepare   specimen, 

695;  in  a  case  of  meningitis,  827. 
in  anajmia,  733;  in  bronchitis,  728;  in  chloro- 
sis, 738;  in  diphtheria,  548,  559,  728;  in 
erysipelas,  728;  in  fever,  731;  in  gastro- 
intestinal diseases,  728;  in  hereditary 
syphilis,  728;  in  infectious  diseases,  728; 
in  malarial  fever,  706;  in  multiple  neu- 
ritis, 794;  In  nephritis,  406;  in  nervous 
diseases,  728;  in  perinephritis,  410;  iu 
pneumonia,  .508,  728;  In  rachitis,  728;  in 
scarlet  fever,  645,  728;  in  skin  diseases, 
728;  in  typhoid,  695;  iu  Winckel's  dis- 
ease, 50. 


952 


INDEX. 


Blood  (concluded) 
letting,   local    (see  Venesection),   938. 
pathological  conditions  in  disease,  728. 
reaction  of  pus,  730. 
smear,   method  of  taking,   730. 
Blood-vessels    (see    also   Thrombosis),    dilata- 
tion of,  in  angeioma,  53. 
in  haemophilia,  751;  in  spinal  paralysis,  809; 
in  syphilis,  718. 
Bloody  urine   (see  Hsematuria),   417;  in  diph- 
theria, 552;  in  septic  diphtheria,  554,  559. 
Blue  baby,  369. 
Boil  (see  also  Furuncle),  877. 
Bone-marrow,  in  leukfemia,  735. 
Bones  (see  Fractures,  also  Joints), 
in   hydrocephalus,    815;    in    rachitis,    348;    in 
syphilis,  723;  in  tuberculosis,  723. 
Borborygmus,  299. 
Bothriocephalus  latus,  326. 
Bottle-brush,  158. 
Bottle  feeding,  139. 
formulae,  140. 
rules  for,  139. 
utensils  required  for,  139. 
Bottles,   feeding,  157. 
Bovine  tuberculosis,  518,  530. 
Bowel  movements   (see  Stools). 
Bowels,  inflation  of,  in  intussusception,  325. 
obstruction  of  (see  Intussusception),  321. 
proper  training  of,  22. 
Bow-legs,   3;   in   rachitis,   348,   355. 
Bradycardia,  366;   in  diphtheria,  552. 
Brain,   778;   cerebellum,    779;   convolutions   of, 
779;     difference     between     infantile     and 
adult,  779;   fissure  of  Rolando,   779;   Syl- 
vius,   778;    growth    and    development   of, 
778;  pia  mater,  778;  subarachnoid  space, 
778. 
abscess  of,  843. 
concussion  of,   850. 

engorgement  of,  in  cerebral  pneumonia,  512. 
in  tubercular  meningitis,  820. 
water  on,   814. 
Breast-feeding,     71;     dangers     of     suffocation 
during,  72;  disturbances  during,  73;  dur- 
ing pregnancy,  90;  schedule  for,  71;  sug- 
gestions for,  72. 
Breast  milk  (see  Milk,  woman's). 
Breast-pump,   67,  94. 

Breasts,    massage    of,     during    lactation,    95; 
pear-shaped,   best   adapted   for    nursing, 
89. 
Breathing  (see  also  Respirations),  451. 
Cheyne-Stokes,  in  meningitis,  823;  in  tuber- 
cular pneumonia, ^515. 
in  bronchial  asthma,  455;  in  diphtheria,  553; 
in   dry   pleurisy,   464;    in   empyema,    467; 
in  pleurisy,  with  effusion,  465;  in  tuber- 
culous pneumonia,  515. 
labored,  in  retro-pharyngeal  abscess,  443. 
Breath,  in  alveolar  abscess,  233;  in  lithaemla, 
751;  In  pulmonary  gangrene,   462. 
offensive,   in   stomatitis   gangrenosa,   228. 
Breck's  feeder  for  premature  babies,  29. 


Bright's    disease    (see    Nephritis),    405;    urine 

in,  919. 
Bromide,  administration  of,  per  rectum,  9.39. 

of  ethyl,  as  an  anaesthetic,  931. 
Bronchial    asthma,    455;    etiology,    455;    path- 
ology,   455;    symptoms,    455;    treatment, 
456. 
catarrh,  452. 

glands,  enlarged,  causing  bronchial  asthma, 
455. 
Bronchi,  diseases  of,  450. 
in    bronchitis,    452;    in    tuberculous    pneu- 
monia, 515. 
Bronchitis,    452;    bacteriology,    452;    blood    in, 
728;  diagnosis,  453;  diet  in,  454;  emetics, 
654;    inhalations,    steam,   454;    pathology, 
452;  prognosis,   453;   pulse-rate,   453;   res- 
pirations,   453;    sputum,    453;    symptoms, 
453;  treatment,   454. 
an  early  symptom  of  typhoid,  694. 
complicating  typhoid,  694. 
Broncho-pneumonia,     456;     bacteriology,     457; 
differential    diagnosis    from    atelectasis, 
460;     fibrous    pneumonia,    460;     etiology, 
456;   pathological  anatomy,  457;   physical 
examination,    459;     predisposing    causes, 
457;    prognosis    and    course,    460;    symp- 
toms,   458;    treatment,    460;    antipyretics, 
460;     emetics,     461;     expectorants,     462; 
pneumonia  jacket,  461. 
complicating   diphtheria,   559;    measles,    636; 

pertussis,  488;  variola,  685. 
sequela,  tetany,  798. 
tuberculous,  535. 
Broths,   907. 
Buhl's  disease,   50. 
Bulgarian  milk,  183. 

Bulimia,  254;   a  symptom  of  hysteria,  2.54. 
Burns,  88L 

Buttermilk  feeding,  182;  how  to  prepare,  183. 
Byrd  method  of  resuscitation,  43. 

Caffeine,  effect  of,  213. 
"Caking"  of  breast,  95. 
Calcined  magnesia,  141. 
Calculi,  giving  rise  to  bloody  urine,  417. 

in   bladder,    420;    diagnosis,    420;    symptoms, 
420;  treatment,  420. 

urethral,  420. 

vesical,  420. 
Caloric  method  of  feeding,  166. 
Cancrum  oris  (see  Stomatitis  Gangrenosa),  227. 
Cane  sugar,  119. 
Cantharidal  collodion,  938. 
Capillaries    in    haemophilia,    752;    in    malarial 

fever,  710. 
Caput  succedaneum,  58. 
Carbolic  acid  as  a  disinfectant,  935. 
Carcinoma,  887. 
Cardiac  diseases,  classification  of,  366. 

paralysis,  563;  symptoms,  563;  in  dysentery, 
285. 
Carious  teeth,  in  rachitis,  346. 


INDEX. 


953 


Carious  teeth  (concluded), 
possible     point     of     entrance     of     tubercle 
bacilli,  518. 
Casein,    125;    in    cows'    milk,    63;    in    woman's 

milk,  62,  66. 
Caseinogen,  121. 

Casts  in  urine,  in  nephritis,  407. 
Catarrh,  acute  nasal,  425;   diagnosis,   425;  eti- 
ology, 425;  symptoms,  425;  treatment,  426. 
bronchial,  452. 
follicular,  431. 
gastric,  428. 
in  syphilis,  719. 
naso-pharyngeal,  428. 
with  adenoid  growths,  425. 
Catarrhal  conjunctivitis,  S61. 
croup,  444. 
epidemic,  fever,  479. 
jaundice,  251. 
nephritis,  656. 
pneumonia,  456. 
proctitis,  331. 
Cavities    of    the    lung,    in    pulmonary    tuber- 
culosis,  536;   in  tuberculous  pneumonia, 
514. 
Cellulitis,   complicating  vaccination,   686. 

of  neck,  in  scarlet  fever,  655. 
Centrifugal  milk-testing   machine,   117. 
Cephalheematoma,  57;  spurious,  58. 
Cereal  milk,  197;  analysis  of,  198. 
Cerebellum,  779;  abscess  of,  843. 
Cerebral  abscess,  843. 
congestion,  in  pneumonia,  512. 
haemorrhage,  in  pertussis,  489. 
hernia,  817. 

hyperaemia,   in  insolation,   851. 
paralysis,  834. 
pneumonia,  502. 
Cerebro-spinal  meningitis,   824. 
Cerebrum,  779. 

Certified  milk  in  New  York  City,   103. 
Cestodes,  326. 

Chatillon  weight  scale,  216. 
Chemical    examination    of    cows'     milk,     116; 
gastric   contents,    915;    urine,    917;    wom- 
an's milk,  65. 
Chest,  in  broncho-pneumonia,  636;  in  cerebral 
pneumonia,  507;   in   chronic  pericarditis, 
377;   in   empyema,   476;   in  pleurisy  with 
effusion,    465;    in    rachitis,   347;    in   spas- 
modic laryngitis,  445. 
strapping     of,     in     dry     pleurisy,     464;     in 
pleurisy  with  effusion,  466. 
Cheyne-Stokes      respiration,      in      tubercular 
meningitis,    826;     in    tuberculous    pneu- 
monia, 515. 
Chicken-pox   (see  Varicella),  676. 
Childhood,  1. 

Chills,   in  diphtheria,   551;   in  orchitis  compli- 
cating rnumps,  758;  in  perinephritis,  410. 
Chloasma,   873. 

Chloral  hydrate,  in  convulsions,  783. 
Chloride  of  lime,  as  a  disinfectant,  935. 


Chloroform,'  930;   in  bronchial  asthma,  456;  in 

control  of  spasms,  783. 
Chlorosis,    737;    diagnosis,    738;    etiology,    7-37; 
pathology,     737;     prognosis,    738;     symp- 
toms, 7.38;   blood  in,  738;  treatment,  738; 
exercise,  738;  nutrition,  739. 
Chocolate,  212;  how  to  prepare,  905. 
Cholera    infantum,    302;    resembling    typhoid, 

696. 
Choleriform  diarrhoea,   302. 
Chorea,    786;    course,    789;    etiology,    786;    ade- 
noids,    787;     overstudy    in     school,     787; 
polypoids,  787;  sedentary  life,  787;  path- 
ology,    788;     prognosis,     789;    symptoms, 
788;  heart,  789;  treatment,  789;  rest,  789. 
Chvostek's  phenomena,  799. 
Circulation,  changes  in,  at  birth,  361. 

foetal,  36L 
Circumcision,   tuberculosis   infection  through, 
519. 
in  treatment  of  masturbation,  797. 
operation  for,  398. 
Cirrhosis  of  the  liver,  384. 
Cleft  palate,  54;   feeding  in,  54. 
Clothing,   19;    abdominal   band,    20;    for      feet, 
19;  in  summer,  19;  in  winter,  19;  night, 
20. 
Clinical  thermometers,   disinfection  of,  934. 
Clitoridectomy,   in   masturbation,   797. 
Cocaine  as  an  intra-spinal  anaesthetic,  9.32. 
Cocoa,  211;  how  to  prepare,  905. 
Coffee,  213;  contraindications,  213;  indications, 

213. 
Cold,  as  an  antipyretic,  461;  in  typhoid,  699. 
compresses,  461. 
ice  collar,  in  tonsillitis,  4.30;  bag,  in  typhoid, 

701. 
pack,  485;  in  chorea,  790;  in  pneumonia,  510. 
sponge  bath,  23. 
spray  bath,   in  hysteria,  793. 
Colic,  a  symptom  of  worms,  328. 
caused   by   excess  of  sugar,   121;   by  proteid 

indigestion,   96. 
in  breast-fed  babies,  297. 
intestinal,  296. 
Colicystitis,   419;  bacteriology,  419;   pathology, 

419;  symptoms,  419;   treatment,  420. 
Colitis  (see  Ileo-colitis),  281. 
amoebic,   281. 
diphtheritic,  281,  282. 
mucous,  in  syphilis,  T19. 
Collapse,  in  diphtheria,  553;  in  dysentery,  285. 

pulmonary   (see  Atelectasis  Pulmonuni). 
Colles's  law,  717. 

Collodion,  cantharidal,  9.38;   iodoform,   in  tub- 
ercular    meningitis,     823;     salicylic,     in 
mumps,  757. 
Colon    bacillus,    in    bronchitis,    452;    In    peri- 
nephritis, 409. 
flushing,   in  athrepsia   infantum,   360;   in   In- 
testinal  colic,   298. 
irrigation  of,  in  diarrlura,  277;  in  dysentery, 
286;   in  typhoid,  699. 


954 


INDEX. 


Colored  race,  mortality  iu,  from  tuberculosis, 

525. 
Colostrum,  61;   analysis  of,  64;   corpuscles  of, 

61;  proteids  in,  87. 
Coma,    in    cerebral    pneumonia,    501;    in    in- 
fluenza, 482;  in  pachymeningitis,  8^2;   in 
scarlet  fever,   665;   in  tubercular  menin- 
gitis,  823. 
to  relieve,  512. 
Combustio  (see  Burns),  881. 
Composition  of  cows'  milk,  99;  woman's  milk 
compared    with    different    infant    foods, 
204. 
Concussion  of  the  brain,   850. 
Condensed  milk,    191;   analysis  of,    192;   quan- 
tity of  sugar  in,  191. 
causing  scurvy,  335. 
Condylomata,  in  syphilis,  720. 
Congenital  (see  also  Fcetal)  abnormalities,  53. 
adenoids,  55. 
cysts  of  the  kidney,  58. 
dislocation  of  hip,  899. 
heart  lesions,  369. 
idiocy,  846. 

malformations,  53;  of  the  rectum,  59. 
obliteration  of  the  bile-ducts,  35. 
sacral  tumor,  58. 
stenosis  of  the  larynx,  56,  720. 
Congestion  of  the  liver,  382. 
Conjunctiva,  infection  of,  862. 

inflammation  of,  in  acute  nasal  catarrh,  426. 
Conjunctivitis,  acute  catarrhal,  861;  cleansing 
the  eye  in,  861. 
diphtheritic,   863. 
membranous,   863. 
phlyctenular,  868. 
Constipation,     286;     causes,    287;    anatomical, 
287;    mechanical    obstruction,    288;    sys- 
temic, 288;  proteid  indigestioH,  96;  steril- 
ized  milk    feeding,    162;   symptoms,    290; 
treatment,    290;     cold    water    injections, 
292;    diet,    294;    electricity,    293;    enema, 
291;  massage,  293;   suppositories,   292. 
alternating  with  diarrhoea,  252. 
in  chlorosis,  738;  in  cretinism,  760;  in  diph- 
theria, 553. 
to    correct,    in    bottle-fed    infants,    114;    in 
breast-fed  infants,  97,  290. 
Convulsions,  781;  diagnosis,  782;  etiology,  781; 
pathology,    782;    symptoms,    782;    treat- 
ment, 783. 
a  symptom  of  worms,  328. 
during  teething  period,  6,  783. 
epileptic,  802. 

in  auto-intoxication,  322;  in  cerebral  pneu- 
monia, 501;  in  diphtheria,  553,  559;  in 
dysentery,  285;  in  hydrocephalus,  815; 
in  influenza,  480;  in  lithsemia,  751;  in 
meningitis,  826;  in  pachymeningitis,  833; 
in  pertussis,  489;  in  post-scarlatinal 
nephritis,  659;  in  scarlet  fever,  647,  650; 
in  typhoid,  693. 
lumbar  puncture,  783. 


Cord,   umbilical,    management  of,   16;   separa- 
tion of,  1. 
Corpuscles  of  blood,  726. 
Coryza,  425. 
in  measles,  630;   in  rubella,  623;  in  syphilis, 
723. 
Cough,  croupy,  444,  557. 
hacking,  in  variola,  685. 

in  acute  tuberculosis,  530;  in  croup,  444;  in 
dry  pleurisy,   463;   in  pertussis,   487,   488; 
in  pleurisy  with  effusion,  465;  in  tuber- 
culous pneumonia,  515;  in  variola,  685. 
night,  448. 
reflex,  449. 
spasmodic,  448. 
useless,   449. 
whooping,  487. 
Coughs  of  reflex  origin,  448. 
Counter-irritants,   462. 

Cow,   breed  of,   best  adapted   for  infant  feed- 
ing, 99,  101;  age  of,  100. 
Ayrshire,  101;   Devon,   100;   Durham  or  Short- 
horn, 100;  Holstein-Friesian,  101. 
care  of,  102. 

time  and  stage  of  milking,  100. 
Cows'  milk,  albuminoids  in,  125. 
care  of,  102. 
properties  of,  63. 
Coxitis   (see  Morbus  Coxarius),   898. 
Cranio-tabes,  a  symptom  in  rickets,  346. 
Cranium   (see  Skull). 
Cream,  bacteria  in,  136. 
Biedort's   mixtures,  134. 
condensed,   191. 
dipper,  132. 
estimation  of,  131. 
for  home  modification,  131. 
gauge,  118. 
how  to  procure,   131. 
mixtures,   133. 
pasteurization  of,  132. 
ripening  of,  135. 
Crede's     method     of     preventing     ophthalmia 
neonatorum,  863. 
ointment,    in    scarlet   fever,   671;    tubercular 
meningitis,  823. 
Cretinism,    760;    diagnosis,    762;    etiology,    760; 
pathology,     760;     prognosis    and    course, 
771;  symptoms,  760;   treatment,  771. 
thyroid  implantation  in,  772. 
Crisis,  in  pneumonia,  507,  508;  blood,  508. 
Croup,    catarrhal,    444;    symptoms,    444;    prog- 
nosis,   445;    treatment,    445;   emetics,   444, 
447;  steam  inhalations,  446. 
kettle,  447;   spasmodic,  444. 
Croupous,   enteritis,  282. 
(esophagitis,  234. 
proctitis,   332. 
stomatitis,  226. 
tonsillitis,  432. 
Cry,  as  diagnostic  aid,  13. 
from  earache,  13;  from  hunger,  13. 


INDEX. 


955 


Cry  (concluded). 
in    cerebral    disease,    13;    in    croup,    13;    in 
marasmus,    13;     in    pneumonia,    13;    in 
tubercular  peritonitis,  13. 

Cryptorchidism,  399. 

Cupping,  dry,  93S. 
in  bronclio-pncumonia,  462:  in  dry  pleurisy, 
464;  in  hematuria,  417;  in  influenza,  4S5; 
in  meningitis,  831;  in  severe  dyspnoea  of 
lobar  pneumonia,   512. 

Curvature  of  the  spine,  897. 

Cutaneous  tuberculin  reaction,  533. 

Cyanosis,  in  acute  tuberculosis,  530;  in  bron- 
chial asthma,  4:35;  in  broncho-pneu- 
monia, 458;  in  diphtheria,  581,  584;  in 
hydropericardium,  378;  in  pulmonary 
tuberculosis,  538. 
of  nails,  in  malarial  fever,  714. 

Cyclic  vomiting,   258. 

Cyclops,  818. 

Cyst,  congenital,  of  kidney,  58. 

Cystitis,  acute,  420;  etiology,  421;  symptoms, 
421;  treatment,  421;  chronic,  421;  prog- 
nosis, 422;  symptoms,  421;  treatment, 
422. 

Deafness,  as  a  symptom,  435;  caused  by  pres- 
ence of  adenoids,  439;  following  measles, 
639;  following  meningitis,  831;  scarlet 
fever,  661;  with  hypertrophy  of  tonsils, 
435. 
Decubitus,  609. 
Deformities,  congenital,  53. 

in  rachitis,  341,  354. 
Degeneration,  reaction  of,  779. 
Delirium,  in  meningitis,  826. 
Dentition,  5;  symptoms,  5;  treatment,  6. 
before  birth,  7. 
delayed,  7. 
difficult,  6. 

eruption  of  first  teeth,  7. 
in  cretinism,   760;   in  rachitis,  5. 
of  first  teeth,  7;  permanent  teeth,  7. 
Depressed  sternum,  57. 
Descensus  ventriculi,   255. 
Desquamation,  following  antitoxin  rash,  556. 
in   measles,    633;   in   rubella,    625;    in   scarlet 
fever,  648,  649;  in  variola,  682. 
Development,  arrest  of,  in  idiocy,  846;  mental, 
in  cretinism,  760. 
of  the  body,  5;  of  the  infant,  1;  of  the  vari- 
ous senses,  2,  3. 
Diabetes  insipidus,  416. 

Diabetes  mellitus,   419;   prognosis,   419;   symp- 
toms,  419;   treatment,   419. 
following  pertussis,  489. 
Diacetonuria,   415. 

Diagnostic  points  in  auscultation,  450;  breath- 
ing, 450;  resonance,  percussion,  4.50; 
vocal,  450;  rhythm,  450. 
suggestions,  9;  cry,  13;  eye  aphorisms,  12; 
gestures,  13;  pulse-rate,  10;  respiration, 
11;  sleep,  14:  temperature,  11;  throat, 
13;  tongue,  13;  x-ray,  14. 


Diaphoretics,  hot  air  bath,  606;  hot  pack,  665; 
hot  saline  injections,   667. 
oiled  silk  jacket,  514. 
Diaphyses,  in  scurvy,  337. 
Diarrha-a,  276;  causes,  276;  treatment,  277. 
as  a  symptom  of  disease,  277. 
complicating  measles,  640;  scarlet  fever,  660. 
fat,  264. 

in    diphtheria,    553,    560;    in    malarial    fever, 
714;  in  syphilis,  719;  in  typhoid,  693,  697. 
nervous,  277. 
Diastase,  155. 

Diastatic  enzyme,   in  human  milk,   59;   in  in- 
testinal   contents,    69;   in   stool   of  nurs- 
ling,  69. 
Diastolic  murmurs,  307. 
Diazo  reaction,   in  tuberculosis,  530;  in  urine, 

923. 
Dietary,  905. 
Diet  (see  also  Feeding), 
from    1    year    to    15    months,    153;    from    18 
months  to  3  years,  153;  from  3  years  to 
10  years,  153;  articles  allowed,  154;   arti- 
cles forbidden,  154. 
in  acute  gastric  catarrh,  246;  in  auto-intoxi- 
cation, 322;  in  chlorosis,  739;  in  constipa- 
tion, 294;  in  diarrhoea,  277;  in  diphtheria, 
576;     in     dysentery,     285;     in     gastritis, 
chronic,    142,    252;    in    gastro-duodenitis, 
249;  in  intestinal  indigestion,  acute,  300; 
chronic,    301;    in    litheemia,    751;    in   milk 
infection,    acute,    306;    in    pleurisy   with 
effusion,  466;  in  pyelitis,  413;  in  rachitis, 
253;  in  rheumatism,  744;  in  scarlet  fever, 
667,  668;  in  scurvy,  336;  in  tuberculosis, 
534;    in    typhoid,    700;    in    ulcer    of    the 
stomach,  258. 
of  a  nursing  mother,  77,  79;  of  a  wet  nurse, 

86. 
salt  free,  667. 
Diffuse  cellulitis,   in  scarlet  fever,  655. 
Digestive  system,  diseases  of,  222. 
Dilatation    of   the  stomach,   acute,    253;    diag- 
nosis,  254;   etiology,  253;   pathology,    254: 
prognosis,     254;     symptoms,     254;     treat- 
ment, 254. 
in  chronic  gastritis,  251. 
Diphtheria,  acute,  539. 
bacillus,  539,  541,  544;  differential  stain,  540. 
in  bronchitis,  452. 
true  and  false,   545. 

Klebs-LoefBer,     541;     characteristics    of, 
543;  growth  on  blood  serum,  544. 
bacteriology,  541;  mixed  infection,  573;  mode 

of  infection,  539,  543. 
chronic,    617;    diagnosis,    618;    isolation,    618; 
prognosis    and    course,    618;    treatment, 
618. 
complications,  558. 
anjEmia,  561. 
aphasia,  559. 
broncho-pneumonia,  559. 
cerebral  thrombosis,  559. 


056 


INDEX. 


Diphtheria  (concluded). 

couvulsions,  559. 

diarrhoea,   560. 

embolism,  559. 

empyema,   559. 

endocarditis,  559. 

enteritis,  5C1. 

gastritis,   560. 

hipmophilia,  559. 

haemorrhages,  559. 

heart,  559. 

measles,  640. 

meningitis,  559. 

mumps,  559. 

myocarditis,  559. 

nephritis,  560. 

omphalitis,   ?,Z,   551,   560. 

otitis,  559. 

paralysis,  560,  577. 

pleurisy,  559. 

scarlet  fever,  652,  661. 
course,  .550,  563. 
diagnosis,   556;    bacteriological,    557;    how   to 

take     a     culture,     .557:     premembranous 

stage,  558. 
differential  diagnosis  from  catarrhr  1  angina, 

558. 

peritonsillar  abscess,  558. 

thrush,  558. 

tonsillitis,  ulcerative,  558;  follicular,  558. 
etiology,  539. 
extubation  in,  613. 
follicular  forms,  554. 
immunization  in,  566. 
intubation  in,  579. 
isolation,  565. 
local,  551. 

nasal,  551;  symptoms,  551. 
pathology,    546;     blood,     548;    hjemorrhages, 

548,  559;   lesions,  546;   lymph   nodes,   548; 

membrane,  546. 
predisposing  factors,   539. 
prognosis,   464. 
j)rophylaxis,  .564. 

pseudo  or  false,  540,  619;  mortality,  621. 
septic,  553. 
symptoms,  550. 

toxin,   effect  of,   on   nervous  system  of  ani- 
mals, 549;  on  heart,  550. 
tracheotomy,  615. 
treatment,     antitoxin,     570;      dietetic,     575: 

hygienic,    560;    medicinal,    576;    modern, 

569. 
Diphtheria  antitoxin,  dose  required,  571. 
dry,  571. 

immunizing  dose,  566. 
Indications  for  second  and   third  injections, 

572. 
influence  of,   on  mortality,   577. 
in    treatment    of    membranous    ophthalmia, 

S46. 
limitations  ot,  567. 
manner  of  administering,  570. 


rashes,    555;    desquamation    following,    55^; 

site  of  eruption,  556. 
result,  general,  567;  with  and  without,  582. 
Diphtheritic  colitis,  281,  282. 
conjunctivitis,  863. 
.dysentery,  282. 
oesophagitis,   234. 
omphalitis,  33,  551. 
paralysis,     561,      563;      simulating     anterior 

poliomyelitis,  563. 
rhinitis,  550. 
stomatitis,   226. 
Diphtheroid,  618. 
Diplegia,  hemorrhage  causing,  778. 

spastic,   834. 
Diplo-bacillus  of  Morax,   862. 
Diplococcus,  Fraenkel,  in  broncho-pncumonla, 
457;   in  lobar  pneumonia,  498. 
pneumoniae,  457;  stain  for,  929. 
in  broncho-pneumonia,  457;  in  pleurisy  with 

effusion,  464. 
intracellularis,  827. 
Disease,   diagnosis  of,  10,  12. 
peculiarities  of,  9. 
symptoms  of,  9,  12. 
Disinfection,   934. 
as  a  means  of  prevention,  934. 
in    diphtheria,    564;    in    Infectious    diseases, 
934;    in    pertussis,   489;    in    scarlet   fever, 
664;   in  typhoid,  700;   in  variola,  685. 
of  clinical  thermometers,  934;  of  hands,  934; 
of  sputa,  935;  of  urine  and  feeces,  935;  of 
water  closets,   935. 
Dislocation  of  the  hip,  congenital,  899. 
Displacement  of  the  heart,  15,  884. 
liver,  382. 
spleen,  386. 
stomach,  255,  257. 
Diverticulum,   Meckel's,   35. 
Dobell's  solution,   427. 
Dropsy    (see   also   Oildema   and   Anasarca),   of 

the  feet,  in  leuksemia,  736. 
Drug  eruptions  resembling  measles,  640. 
Drugs,  administration  of,  936;  per  rectum,  939. 
dosage  of,  944. 

effect  of,  on  woman's  milk,  73. 
in  treatment  of  constipation,  294. 
Dry  cupping,  938   (see  also  Cupping). 
Dry  pleurisy,   463. 
Dry-tap  in  lumba,r  puncture,  830. 
Ductless  glands,   diseases  of,  760. 
Ductus  arteriosus  Botalli,  370;  closure  of,  362. 
Duke's    disease,     674;     period    of    incubation, 
674:  prognosis,  675;  symptoms,  674;  treat- 
ment, 675. 
Duodenal  catarrh,  300. 
Dura  mater,  inflammation  of,  833. 
Dysentery,    281;    bacteriology,    282;    diagnosis, 
285;  pathology,  281;  prognosis,  285;  symp- 
toms,  284;   treatment,   285;   diet,  285. 
fever  curve  in,   283;   amoeb.c,   281;   diphthe- 
ritic, 282. 
Dyspepsia,   242. 
Dyspeptic  asthma,  259. 


INDEX. 


957 


Dyspnoea,  in  broncho-pneumonia,  461 ;  in 
croup,  445;  in  dilatation  of  stomach,  254; 
In  diseases  of  thymus,  773;  in  dry 
pleurisy,  404;  in  hydropericardium,  378; 
in  lobar  pneumonia,  512;  in  papillomata, 
888;  in  pulmonary  tuberculosis,  538;  in 
retro-pharyngeal  abscess,  443;  in  toxic 
scarlet  fever,  650;  In  tuberculous  pneu- 
monia, 515. 
oxygen  in,  513. 

Dysuria,  921. 

Earache,   in  diphtheria,   553;   in  scarlet  fever, 

668. 
Ear,  diseases  of,  854. 
foreign  bodies  in,  860. 
syringe,   856. 
Ears,   bleeding  from,   in  diphtheria,   559. 
in  diphtheria,  553,  559;  in  scarlet  fever,  668. 
inflammation  of,  in  otitis,  854. 
running,  in  syphilis,  723. 
Eberth's  typhoid  bacillus,  689,  690. 
Ecchymoses,     in    purpura,     747;     in     purpura 

hfemorrhagica,  748;  in  scurvy,  337. 
Eclampsia  (see  Convulsions),   781. 

in  epilepsy,  802. 
Ectogenous  streptococcus  infection,  702. 
Ectopia  vesiese  congenitalis,  413. 
Eczema,    869;    etiology,    869;    symptoms,    869; 
treatment,   870. 
associated  with  chronic  gastritis,  252. 
bathing  in,  870. 
in  lithaemia,   751. 
intertrigo,  871. 
rubrum,  870. 

to  relieve  excoriation  of,  149. 
tubercle  germs  in  pus  from,  519. 
Effusion,    in    ascites,    393;    in    hydrocephalus, 
814;  in  nephritis  following  scarlet  fever, 
666;    in    pericarditis,    376;    in    pertussis, 
489;  in  pleurisy,  465. 
Eggs,  nutritive  value  of,  210. 
Elbow-joint  disease,  902. 

Electricity,  in  cerebral  paralysis,  839;  in 
chorea,  790;  in  constipation,  293;  in 
enuresis,  424. 
Emaciation,  in  dilatation  of  stomach,  acute, 
2.54;  in  gastritis,  chronic,  252;  in  hydro- 
cephalus, 815;  in  myelitis,  acute,  806;  in 
tuberculosis,  chronic,  538. 
Embolism,  in  endocarditis,  373;  in  diphtheria, 

559. 
Embolus,  in  endocarditis,  373. 
Emetics,   in  bronchitis,   454;   in   croup,   447;   in 
dyspnoea  of  broncho-pneumonia,   461;   in 
gastric  catarrh,  244. 
Emphysema,     complicating     diphtheria,     5SI); 

pertussis,   489. 
Empyema,   466;   bacteriology,    167;  lourse.   408; 
etiology,   400;    pathology,    407;    prognosis, 
468;     symptoms,      407;      treatment,      409; 
surgical,  469;  anaesthetic,  469. 
chronic,  470. 


complicating    influenza,    482;    measles,    639; 

scarlet  fever,  660;  diphtheria,  559. 
following   pertussis,   489;   pleuro-pneumonia, 

502. 
James    apparatus    for    expanding   the    lungs 

in,  470. 
of  the  mastoid  antrum,  complicating  scarlet 

fever,  654. 
tubercular,  471. 
Enanthem,   in   scarlatina  sine  "angina,   652;   in 

scarlet  fever,  647;  in  measles,  631. 
Eneephalocele,   817. 
Enchondromata,  887. 

Endocarditis,  371;  diagnosis,  373;  etiology,  372; 
pathology,     373;     prognosis    and    course, 
373;   symptoms,  372;  treatment,  374. 
somplicating    chorea,    788;    diphtheria,    559; 

rheumatism,  742. 
following  scarlet  fever,  661;  typhoid,  698. 
malignant,    374;    diagnosis,    375;    pathology, 
374;    prognosis    and    course,    375;    symp- 
toms, 375;  treatment,  375. 
Enemata  (see  also  Rectal  Irrigations), 
continued  use  of,  292. 
how  to  give,  291. 

in    chronic    gastritis,    251;     in    constipation, 
291;  in  dysentery,  284;  in  intestinal  colic, 
298. 
nutrient   (see  Rectal  Feeding), 
oxgall,  251. 
Enteralgia,  296. 
Enteritis,  croupous,  282. 
membranous,  complicating  diphtheria,  561. 
tuberculous,  519. 
Enuresis,  422. 

a  symptom  of  lithaemia,  751. 

causes,     422;     adenoids,     423,    439;     tight 

prepuce,  423. 
in  meningitis,   826. 
prognosis,  423. 

treatment,    423;     mechanical,    423;    elec- 
trical, 424. 
diurna,  422. 
nocturna,  422. 
Enzymes,  127. 

Eosinophiles,    in    pneumonia,    729;    in    scarlet 
fever,     729;     in     skin     diseases,     728;     in 
syphilis,  728. 
Epidemic  catarrhal  fever,  479. 
cerebro-spinal   meningitis,   824. 
hysteria,  792. 
Epilepsy,  801. 

aura   in,  803. 

differential  diagnosis,  804;  from  hysteria, 

804. 
etiology,  801. 

following  convulsions,   801. 
pathology,     802;     intestinal     putrefaction, 

803;   urine,  803. 
predisposing  factors,  801. 
prognosis  and  course,  804. 
symptoms,   803. 

treatment,   804;   operative,   805. 
grand  mal  form,  803. 


958 


INDEX. 


Kpilepsy  (concluded), 
idiopathic,  802. 
petit  mal  form,  803. 
Epiphyses,   in  rachitis,  348;   in  syphilis,  724. 
Epiphysitis,  acute,  903. 
Epispadias,  399. 
Epistaxis,  in  hfEmophilia,  752;  in  measles,  C42; 

in    pertussis,    489;    in    pulmonary    tuber- 
culosis, 538;  iu  septic  diphtheria,  554;  in 

thrombosis    of   cerebral   sinuses,    8G0;    in 

toxic  scarlet  fever,  650. 
Epithelial    desquamation    of    the   tongue,    231 ; 

treatment,  232. 
Erb's  paralysis,  40. 
Eructations,   in  chronic  gastritis,  252;  iu  gas- 

troptosis,  255. 
of  gas  from  excess  of  sugar,  121. 
sour,  in  intestinal  indigestion,  299. 
Eruption,  artificial,   19. 
drug,  resembling  measles,  640. 
following   injection   of   diphtlieria   antitoxin, 

555. 
in  chloasma,  873;   in  erythema  infectiosum, 

674;    in    influenza,    480;    in   measles,    630, 

632;    in   meningitis,   826;    in   rubella,   624; 

in  scabies,   883;   in  scarlet  fever,   649;   in 

stomatitis  aphthosa,  223,  224;  in  syphilis, 

720;   in  typhoid,   G95;  in  vaccinia,   688;   in 

varicella,  676:  in  variola,  681. 
Eiysipelas,  702. 

blood  in,  728. 

complications,  704. 

etiology  and  bacteriology,  702. 

pathology,  703. 

prognosis,  704. 

treatment,  705. 
migraine,  703. 
Erythema,  871. 

differentiated  from  syphilis,  720,  871. 

following    injection    of    diphtheria    anti- 
toxin, 555. 

on  buttocks,  871. 
Erythroblasts,  728. 
Erythrocytes,  726;  in  syphilis,  728. 
Eskay's    albuminized    food,    200;    analysis    of, 

201. 
Ether  as  an  anaesthetic,  931. 
Ethylchloride,  931. 
Eucasin,  205. 
Estlander's    operation    in    chronic    empyema, 

471. 
Eustachian  tube,   in  adenoid  vegetations,   438; 

in  otitis  media,  854. 
inflammation  of,  in  rhinitis,  426. 
Examination   of  heart,   362;   of   lungs,   450;   of 

patient,  9. 
Exercise,  23  (see  also  Gymnastics). 

in  constipation,  292;   in  lithsemia,  751. 
Exophthalmia      in      thrombosis     of      cenbral 

sinuses,  860. 
Exophthalmic     goiter,     772;     prognosis,     772; 

symptoms  and  diagnosis,  772;  treatment, 

772. 


Exophthalmus,  iu  exophthalmic  goiter,  772. 

in  hydrocephalus,  816. 
Expectorants,  in  broncho-pneumonia,  462. 
Expectoration   (see  Sputum), 
in    bronchitis,    453;    in    pulmonary    tubercu- 
losis, 538;  in  ulcer  of  stomach,  257. 
Exploratory    puncture,    in    empyema,    467;    in 
pleurisy  with  effusion,   465. 
points  to  be  noted  in  making,  467. 
Exstrophy  of  the  bladder,  416. 
Extubation,  613. 

auto,  596. 
Eye,  as  a  diagnostic  aid,  12. 
diseases  of,  861. 

in  chlorosis,   738;   in   chorea,   787;   in   distin- 
guishing  the    still-born    from    the    dead, 
43;    in   dysentery,    285;    in   exophthalmic, 
goiter,   772;   in  gonorrheal  infection,  402; 
in   measles,   630,   639;   in   meningitis,   823, 
826;     in    nystagmus,    785;    in    stomatitis 
gangrenosa,  227. 
prophylaxis   and   treatment  of,   in   the  new- 
born, 32. 
suffusion  of,  in  rubella,  623. 
Eyelid,  in  blepharitis,  8G6;  in  hordeolum,  867; 
in    purulent    ophthalmia,     863;     in    tra- 
choma, 866. 
method  of  everting,  867. 
proptosis  of,   in  scurvy,  337. 

Face,  cyanosis  of,  in  broncho-pneumonia,  458. 
in    adenoid    vegetations,    438;    in    chlorosis, 
738;  in  cretinism,  760,  762;  in  diphtheria, 
septic,  553;  in  nephritis,  407;  in  pertusis, 
488. 
Facial  paralysis,  following  mastoid  operation, 
842;  retro-pharyngeal  abscess,  842. 
in  the  new-born,  842;  prognosis  and  course, 
842;   treatment,  842. 
FaBcal  vomiting,  323. 
Fa;ces  (see  Stools). 
Fainting  (see  also  Syncope). 

in  leukEemia,  736. 
Fat,   determination  of,  117;  cream  gauge,  118; 
Feser's  test,  118;  Marehand's  test,  117. 
diarrhoea,  116. 

in   breast   milk,    87;    to   decrease,    87;    to  in- 
crease, 87. 
in  cows'  milk,  116;  excess  of,  116. 
in  stool,  116. 
Fatty   degeneration,    of   blood-vessels,    835;    of 
newly-born,    50;    in    pernicious    anaemia, 
734. 
growths,  887. 
heart,   366. 
liver,  383,  384. 
Feeble-mindedness    (see    Idiocy    and    Imbecil- 
ity), 845. 
Feeding  (see  also  Diet  and  Gavage). 
bottle  or  hand,  139. 

general  rules  for,  139. 
utensils  required,  139. 
breast,  71. 
buttermilk,  182. 


INDEX. 


959 


Feeding  (concluded). 

caloric  luithod  of,  166. 

Casselberry  method  of,  in  intubation,  595. 

cows'  milk,  139. 

cream,  131. 

flour-ball,  77. 

from  1  year  to  15  months,  90. 

goats'  milk,  182. 

in  acute  milk  infection,  306;  In  athrepsia, 
359;  in  atrophy  and  chronic  gastritis, 
142,  252;  in  bronchitis,  454;  in  cleft 
palate,  54;  in  diphtheria,  575;  in  dys- 
pepsia, 147;  in  hypertrophic  pyloric  sten- 
osis, 250;  in  intubated  cases,  594;  in 
milk  idiosyncrasies,  168;  in  myocarditis, 
380;  in  pertussis,  490;  in  pneumonia,  514; 
in  starvation  and  rickets,  144. 

intervals  of,   139. 

mixed,  72. 

modified  milk,  173. 

of  delicate  or  sick  children,  155;  of  prema- 
ture infants,  28. 

rectal,  454,  576. 

substitute,  156. 
Feeding  bottles,  165;  care  of,  157. 
Feeding  cup,   91. 
Femur  in  rachitis,   348. 
Fermentation  in  chronic  gastritis,  251. 

in   auto-intoxication,   322. 

test  in  urine,  927. 
Ferments,  and  their  actions,  238. 

unorganized,  237. 
Feser's  lactoseope,  118. 
Fever,  472   (see  also  Temperature). 

causes  of,  472. 

how  to  reduce,  511. 

hysterical,  474. 

in  gastric  catarrh,  247. 
Fingers  in  cretinism,   760. 
First  attempts  at  walking,  2. 
Fischer's  corrugated  rubber  intubation  tubes, 

585. 
Fissure  of  the  anus,  331. 
Fistula  in   alveolar  abscess,   233. 
Flatfoot,  896. 

Flatulence  in  gastro-duodcnitis,  250. 
Flaxseed  poultice,  937. 
FIrxner  anti-meningitis  serum,  831. 
Flour-ball  feeding,  77. 
Focal   necrosis,  3S4. 
Fnptal    (see  also  Congenital)  circulation.   361. 

ichthyosis,   46. 

typhoid,   691. 
Fn'tus,  in  syphilis,  716. 
Follicular  forms  of  diphtheria,  554. 

tonsillitis,   431;   resembling  diphtheria,  558. 
Fomentations,  937. 
Fontanel,  775. 

anterior,   775. 

in  cretinism,  760;  in  hydrocephalus,  815;  in 
rachitis,  341,  346. 

posterior,  775. 

premature  closure  of,  775. 


Foramen  Magendie,  in  hydrocephalus,  778. 

ovale,   closure  of,  362. 
Foreign  bodies  in  ear,  860;   larynx,  447;  nose, 

429;    oesophagus,   235. 
Formaldehyde  in  milk,  912;  test  for,  912. 
Formulse  for  bottle-fed  infants,   140,  141. 
Food,   dextrinized,    155;   method   of  preparing, 

155. 
Foods,  infant,  194. 
patent,    193;    composition    of,    as    compared 
with   human   milk,   204. 
Foot  and  mouth  disease  (see  Stomatitis  Aph- 

thosa),  223. 
Fourth    disease    (see    Erythema    Infectiosum), 

674. 
Fractures,  40. 
green  stick,  40. 
during  labor,  40. 
in  rachitis,  348. 
Frankel  diplococcus,  in  lobar  pneumonia,  498. 
Friedrich's    disease    (see    Hereditary    Ataxy), 
808. 
sign,   in  chronic  pericarditis,   377. 
Fright,   causing  chorea,  787;   convulsions,   781. 
Furuncle,  877. 
differential  diagnosis  from  carbuncle,  877. 
in  rachitis,  877;   in  syphilis,  720. 
Furunculosis,   complicating  scarlet  fever,  660. 

Gaertner  mother  milk,  188. 
Gall-bladder,  congenital  absence  of,  35. 
Gangrene,  881. 
complicating     erysipelas,     703;     pneumonia, 

509;  scarlet  fever,  660;  typhoid,  698. 
of  cheeks,   227;   of   genitals,    228;   of   mouth, 

698. 
pulmonary,    462;    diagnosis,    462;    treatment, 

463. 
symmetrical,  883. 
traumatic,  881. 
Gastric    catarrh,    242;    pathology,    243;    prog- 
nosis   and    course,    251;    symptoms,    243; 
treatment,  244. 
contents,   examination  of,  915. 
fever,  resembling  typhoid.  698. 
juice,  chemical  constituents  of,  236. 

influence    of   on    pathogenic    germs,    237, 
238. 
Gastritis,   acute,  242. 

complicating  diphtheria,  .560. 
chronic,   251;   diagnosis,   2.52;   pathology,   251; 
predisposing   causes,   251 ;    prognosis   and 
course,    252;    symptoms,    251;    treatment, 
252. 
Gastrodiaphane   for   translumiiiation   of  stom- 
ach, 254. 
Gastro-duodenitis,    251;    symi)toms,    251;    treat- 

.  ment,  251. 
Gastro-entcrostomy   in   spasm  of  the  pylorus, 

248,  250. 
Gastro-intestinal    disturbance,    causing    asth- 
matic attacks,  455. 
hipmorrhage,  38. 
tract,  in  syphilis,  719. 


960 


INDEX. 


Gastroptosis,  255;  diagnosis,  256;  etiology,  255: 
prognosis    and    course,    257;    symptoms, 
255;   treatment,   257. 
Gavage,  apparatus  for,  29. 
in    cleft    palate,    54;    in    intubated    cases    of 

diphtheria,  594. 
method  of,  in  premature  infants,  30. 
Gelatine  food,  908. 
General  hygiene  of  the  infant,  16. 
Genital  organs,   diseases  of,  395. 
irritation    in    chronic    cystitis,    421;    in    phi- 
mosis, 397. 
Geographical   tongue    (see   Epithelial    Desqua- 
mation), 231. 
German  measles,  622. 
Gestures  as  diagnostic  aid,  13. 
Ginger  poultice,  938. 
Gingivitis,  6;  in  scurvy,  337. 
Glands,  adrenal,  774. 
bronchial,  in  broncho-pneumonia,  459. 

enlarged,  causing  bronchial  asthma,  455. 
cervical,   causing  torticollis,   747. 
in  stomatitis  gangrenosa,  228. 
diseases  of,  753. 

in  adenitis,   754;    in   eczema,   809;   in   leukte- 
mia,    735;    in'  mumps,    757;    in    rubella, 
623;  in  status  lymphaticus,  753;  in  scar- 
let fever,  647. 
peripheral,   in  acute  tuberculosis,  530. 
submaxillary,     in    diphtheria,     551,     553;     in 
scarlet  fever,  647. 
Gland,  thymus,  753. 

thyroid,  760. 
Glomerulo-nephritis,   405. 
Glossitis,   2.32. 

Glottis,  oedema  of,  in  erysipelas,  704;  in  scar- 
let fever,  671;  in  variola,  685. 
spasm    of,    causing    cough,    448. 
Glucose  in  urine,  925. 
Glycogenic  reaction  of  blood,  730. 
Glycosuria,  418. 
in   diabetes  mellitus,   419;    in   pseudo-hyper- 
trophic  paralysis,  920. 
Goats'  milk,  182. 
Goiter,  exophthalmic,  772. 

wet-nurse  with,  81. 
Gonococcus,    401;    in    cystitis,    421;    in    gonor- 
rhoeal  vaginitis,  401. 
stain  for,  929. 
Granular  gastritis,  251. 
ophthalmia,    804;    from    false    or    follicular 
granulation,  865. 
Granuloma,  33. 
Granulomata,  889. 

Graves'    disease    (see    Exophthalmic    Goiter), 
772. 
sign  in  bronchitis,  453. 
Grippe  (see  Influenza),  479. 
Growing  pains,  741,  743. 
Growth  and  height,  5. 

in  diabetes  insipidus,   416. 
Growths  (see  also  Tumors),  abnormal,  SS4. 
Gums,    bleeding,    in    purpura    hemorrhagica. 
748. 


inflamed,   6;    possible  source  of  invasion   of 

tubercle   bacilli,   518. 
in    scurvy,    337;    in    stomatitis    gangrenosa, 
228;  in  toxic  scarlet  fever,  660. 
Gymnastics  (see  also  Exercise),  23. 
in  lateral  curvature  of  the  spine,  897. 
pulmonary,    in    empyema,    470;    in    tubercu- 
losis, 535. 
Genu  recurvatum,  355. 
Genu  varum   (see  Bowlegs),  355. 

Habit-spasm,   differential  diagnosis  from  true 

chorea,  788. 
Haematoma  of  the  sterno-mastoid,  57. 
Hsematuria,    417;    prognosis,    417;    treatment, 
418. 
in    cystitis,    421;    in   malarial   fever,    714;    in 
purpura  hsemorrhagica,   748;   in  pyelitis, 
414;  in  scurvy,  336;  in  symmetrical  gan- 
grene, 883. 
Hcemiplegia  (see  Paralysis  Cerebral),  834. 
HcEmoglobin,  at  birth,  727. 

in  rachitis,  728;  in  diphtheria,  549. 
Hoemoglobinuria,  418. 
in  malarial  fever,   720;   in  symmetrical  gan- 
grene, 883;  in  syphilis,  920;  in  Winckel's 
disease,   920. 
neonatorum,  50. 
paroxysmal,   418. 
Haemophilia,    751;    pathology,    751;    prognosis, 

752;  symptoms,  752;  treatment,  752. 
Haemoptysis,    in   chronic   tuberculosis,   538;   in 

purpura  haemorrhagica,  748. 
Haemorrhage,  cerebral,  in  pertussis,  489. 
following   adenoid   operation,    442;   operation 
for    peritonsillar     abscess,     434;     tonsil- 
lotomy, 435. 
gastro-intestinal,  38;  serum  injections  in,  39. 
in   congenital   obliteration   of  the  bile  duct, 
36;    in    diphtheria,    554,    559;    in    exoph- 
thalmic goiter,  772;  in  leukaemia,  735;  in 
pachymeningitis,  833;  in  syphilis,  719;  in 
typhoid,   097. 
from  bowels,  736;  genital  tract,  417;  kidney, 

417;   stomach,   736,   772. 
internal,  in  typhoid,  697. 
into  subarachnoid  space,  778. 
spontaneous,   37. 
subcutaneous,  in  scurvy,   337. 
umbilical,  38. 
Haemorrhagic  diseases  of  the  newly-born,  37. 
Haemorrhoids,  332. 
Hair,  1;  in  cretinism,  760. 
Hand-feeding  (see  Bottle  Feeding),  139. 
Hands,  disinfection  of,  934. 

in  cretinism,  762. 
Harelip,  54. 
nippls,  54. 
Hay-fever,  resembling  bronchial  asthma,  455. 
Head,  circumference  of,  at  birth,  775. 
in  hydrocephalus,  815;   in  rachitis,  341. 
nodding,  in  spasmus  nutans,   785. 
retraction    of,    in   cerebro-spiual   meningitis, 
826;  in  influenza,  482. 


INDEX. 


961 


Head  (concluded), 
shape  of,  775,  776. 
supplementary,  58. 
sweating,  346. 
Headaches,  784. 
due    to   brain    lesions,    785;    to    general    sys- 
temic   conditions,    784;    to    local    origin, 
784;   to  influenza,  480. 
in   chlorosis,    738;    in   chronic   gastritis,   252; 
in   diabetes  insipidus,    416;    in    lithaemia, 
751;  in  tubercular  meningitis,  823. 
reflex,  784. 

sick  (see  Migraine),   785. 
Heart  and  fcetal  circulation,  361. 
classification   of  cardiac  diseases,  365. 
diagnostic  points,  366. 
diseases  of,  366;  classification  of,  365. 
displacement  of,  17,  884. 
examination   of,   363;    area   of   dullness,    364, 

369;  location  of  apex  beat,  362. 
fatty,  366. 

in    chorea,    789;    in    diphtheria,    552,    553;    in 
gonorrhceal    infection,    402;    in   pertussis, 
489;     in     rheumatism,     742;     in     scarlet 
fever,  659,  665. 
murmurs,    366;    anaemic,    367;    diastolic,    367; 
pericardial,     368;     systolic,     366;     venous 
368. 
palpitation  of  (see  Tachycardia),  366. 
primary  tuberculosis  of,  519. 
position  of,  363. 
reflex  symptoms  of,  366. 
size  of,  362. 

sounds  and  murmurs,  366. 
tension,   363. 

tricuspid  insufficiency,  367. 
■weight  of,  .362. 
Heat-stroke   (see  Insolation),    851. 
Hehner's  test  for  formaldehyde  in  milk,  913. 
Height,    from   birth   to   twentieth   year,    5;    of 

new-born,  male,  5;  female,  5. 
Hemichorea,   788. 
Hemicrania  (see  Migraine),  785. 
Hemiplegia   (see  Cerebral  Paralysis),  834. 
complicating  diphtheria,  559. 
haemorrhage   into   subarachnoid  space  caus- 
ing, 778. 
Hemostatics,  in  acute  tuberculosis,  535. 
Hepatic  abscess,  caused  by  worms,  328. 
Hereditary  ataxy,  808. 

Hernia,    395;    diagnosis,    396;    from   hydrocele, 
396;    causes,    395;    prognosis,    396;    symp- 
toms, .396;  treatment,  396;  surgical,  307. 
following  pertussis,  489. 
in  the  new-born,  395. 
umbilical,  325;  truss,  326. 
Herpes,   circinatus,   878. 
tonsurans,  878. 
zoster,  873. 
Hiccough  (see  Singultus). 
Hinged  bucket  for   extracting  foreign   bodies, 

235. 
Hip,    congenital    dislocation    of,    899;    etiology, 
899;  symptoms,  900;  treatment,  900. 


bilateral  dislocation,  900. 

unilateral  dislocation,  900. 
Hip-joint  disease  (see  Morbus  Coxarius),  898. 

from  perinephritis,  410. 

tubercular,  898. 
Hips,  in  lateral  curvature  of  the  spine,  897. 
Hives  (see  Urticaria),  871. 
Hoarseness,  in  syphilis,  723. 
Hodgkin's  disease,  757. 
Home  modification  of  milk,  139. 
Hordeolum,  867.' 
Horismascope,  922. 
Horlick's  lunch  tablets,  153. 

malted  milk,  196;  analysis  of,  196. 
Hot  air  bath,  660. 

compresses  or  fomentations,  937. 
Hot  and   cold  bath,   in  asphyxia  neonatorum, 

44. 
Human  milk  (see  Milk,  Woman's). 

diastatic  enzyme  in,  69;  new  reaction  of,  69; 
properties  of,  62. 

to  preserve,  70. 
Humanized  milk,  203,  909. 
Hutchinson's  teeth,  721. 
Hydrencephalocele   (see  Meningocele),  817. 
Hydrencephaloid,  .342. 
Hydrocele,   397. 

Hydrocephalus,  814;  etiology,  814;  pathology, 
814;  prognosis  and  course,  815;  symp- 
toms, 815;   treatment,  815. 

external,  814. 

foramen  Magendie  in,  778. 

internal,  814. 

intra-uterine,   817. 
Hydrochloric    acid,    function    of,    in    stomach, 
237. 

in  gastric  contents,  915. 

test  for  formaldehyde  in  milk,  913. 
Hydropericardium,  378;   pathology,  .378;   treat- 
ment, 378. 
Hygiene,   of  infant,    16;    fresh   air,   20;   proper 
training,  22. 

of  mouth,  16. 

nervous  system,  23. 

stable,  109,  110;  cows,  110;  milk,  110;  milker, 
110. 
Hyperaemia,  cerebral,  in  insolation,  852. 
Hypera?sthesia,   in   acute  myelitis,   806. 

in  multiple  neuritis,  794. 
Hyperorexia  (see  Bulimia),  254. 

in  acute  tuberculosis,  530. 
Hyperthyrea  (see  Exophthalmic  Goiter),  772. 
Hypertrophic  stenosis  of  the  pylorus,  249. 

gastro-enterostoniy  in,   249. 

tonsillitis,  432;  etiology,  435;  symptoms,  435; 
treatment,  436. 
Hypertrophy  of  muscles,  842;  of  tongue,  232. 

of  tonsils,  434. 
Hypodermic  medication,  943,  944. 

In  spasmodic  laryngitis,  447. 
Ilypodermodysis,    in   scarlet   fever,   666. 

in  typhoid,  699. 
Hypospadias,  3.99. 


962 


INDKX. 


Hysteria,  791;  diagnosis,  791;  differential  diag- 
nosis, 804;  from  epilepsy,  SOI;  patliology, 
791;    prognosis    and    course,    792;    treat- 
ment,  792. 
epidemics  of,  792. 

Ice-bag,  throat,   134. 

coil,   in  tubercular  meningitis,   823. 
Ice  cream,  212. 
Ichthyosis,   fcetal,   46. 
Ichthyol  ointment,  871. 
Icterus,  381;  urine  in,  918. 

complicating    pseudo-leuksemic    antemia, 
737;   scarlet  fever,   GGO. 
neonatorum,  48. 
Idiocy,  845;  diagnosis,  84G;  etiology,  8!.5;  path- 
ology,   850;     symptoms,    850;    treatment, 
850. 
congenital,  846. 

infantile  amaurotic  family,  849. 
Mongolian,  846. 
Ileo-colitis  (see  Dysentery),  281. 
Imbecility,  845. 

Immunity  conferred  by  woman's  milk,  69. 
Immunization  in  diphtheria,  566. 
Imperforate  recturh,  59. 
Imperial  granum,  199;  analysis  of,  199. 
Impetigo,  874;   symptoms,  874;  treatment,   875. 

resembling  varicella,  678;  variola,  683. 
Inanition,     in     athrepsia     infantum,     3.j7;     in 

chronic  gastritis,  252.  , 

Incubators,   25,  31. 
Indican,  in  tuberculosis,  530. 

test  for,  in  urine,  925. 
Indicanuria,  415. 

Indigestion,    acute    intestinal,    299;    prognosis, 
300;  symptoms,  299;  treatment,  .300;  diet, 
300. 
chronic    intestinal,    300;    diagnosis,   301;    eti- 
ology,   300;    prognosis,    301;    symptoms, 
300;   treatment,   301. 
Infancy  and  childhood,  1. 
Infant  feeding,  61. 
Infant  foods,  194. 
Infantile  atrophy,  356. 
spinal  paralysis,  809. 
Infarctions,  uric  acid  in  kidneys,  918, 
Infectious  diseases,  472;  table  of,  476, 
Inflamed  gums,  6;  treatment  of,  6. 
possible     source     of     invasion 
bacilli,  518. 
Inflammation  of  the  dura  mater,  833. 
Inflammatory  rheumatism   (see  Rheumatism). 

740. 
Inflation  of  bowel,  in  intussusception,  325. 
of  lungs,  44. 

of  stomach,  in  gastroptosis,  2.')6. 
Influenza,  479. 

complications  of,  476,  482;  empyema,  482; 
nephritis,    482;    neuritis,    482;    otitis, 
482. 

course,  482. 

diagnosis,   480;   from   measles,   480;    scar- 
let fever,  480;  typhoid,  480. 


920. 
477. 


of     tubercle 


duration,  476. 
eruption,  480. 
Isolation,  476. 
prognosis,  482. 
symptoms,   476,  480. 
treatment,  483. 
gastro-enteric  type,  481. 
nervous  type,  482. 
respiratory  type,  481. 
Inhalations,    in    asthma,    456;    in    bronchitis, 
454;     in     cerebral     pneumonia,     505;     in 
croup,  446,  447;  in  pertussis,  494. 
Injections  (see  also  Rectal  Injections), 
intralaryngeal,   446. 
intravenous,  in  erysipelas,  705. 
of  horse  serum,  31,  39. 
subcutaneous,  in  scarlet  fever,  666,  672. 
Insolation,    851;     diagnosis    from    meningitis, 
851;      pathology,      851;      prognosis,      85  L; 
symptoms,  851;  treatment,  852. 
Insomnia  (see  also  Restlessness  at  Night), 
from  use  of  coffee,  213. 

in    cretinism,    764;    in    gastroptosis,    255;    in 
hysteria,  792;  in  influenza,  481. 
Intermittent  fever  (see  Malarial  Fever),  706. 
Interstitial  hepatitis,  384. 
Intertrigo  eczema,  871. 

Intestinal    colic,    296;    causes,    296;    diagnosis, 
297;  symptoms,  296;  treatment,  297. 
hsemorrhage,  697. 

indigestion,      acute,      299;      symptoms,     299; 
treatment,  300. 
chronic,   300;   diagnosis,   301;   etiology,   300; 
prognosis,     301;     symptoms,     300;     treat- 
ment, 301. 
obstruction,    from    intussusception,    321;    in 

constipation,  289. 
perforation,  in  typhoid,  693,  697. 
Intestines,   260;    ctecum,   261;   course  of  colon, 
260;    large,    260;    length   of,   260;    sigmoid 
flexure,  261;  abnormalities  of,  289;  small, 
261;     transverse    colon,    261;    vermiform 
appendix,  261. 
absorption   of  fat   in,   261. 
bacteria  of,  266. 
formation  of  gas  in,  261. 
haemorrhages  from,  697,  772. 
perforation  of,  697. 
physiology  of,  261. 

ulceration    of,    in    newly-born,    287;    tuber- 
cular,  538. 
Intracranial   injections,   832. 
Intralaryngeal  injections,  446. 
Intra-spinal  anaesthesia,  932;  injections,  832. 
Intravenous  injections,  in  erysipelas,  705. 
Intraventricular    method    of    serum    injection, 

828. 
Intubation,  579;  false  passage  in,  592,  612. 
in  aphonia  spastica,  593. 
in   cicatrical    stenosis,    592;   due   to   syphilis, 

irritants  or  traumatism,  592. 
in  deformities  of  larynx,  593. 
in  diphtheria,  579. 


INDEX. 


963 


Intubation  (concluded). 

accidents   during,   591;   false  passage   in, 

612. 
after-effects  of,  603. 
effect  of,   in  upper-air  passages,   597. 
feeding  in,  594;  Casselberry  method,  595. 
indications  for,   579. 
method    cf,    dorsal,    586;    O'Dwyer,    586; 

upright,   586. 
mortality,  593. 
results,  580,  581. 
in  papilloma  of  larynx,  593. 
in  pertussis,  489. 
Intubation  instruments,  584. 
Fischer's  corrugated  rubber  tube,  585. 
medicated,  tubes,  612. 

specially  constructed  rubber  tubes,  585,  592. 
Intussusception,     322;     diagnosis,     322;     prog- 
nosis,   324;    symptoms,    322;    f cecal  vom'.t, 
322;   treatment,   325;  surgical,  325. 
colic,  322. 
ileo-colic,  322. 
ileo  or  jejunal,   322. 
Invagination   of   bowel    (see   Intussusception), 

321. 
Invertin,   function  of,  238. 

lodophile  reaction  of  blood   (see  Blood  Reac- 
tion), 730. 
Iritis,  in  meningitis,  826. 
Irrigation  (see  also  Rectal  Irrigation), 
chamomile,  in  dysentery,  386. 
cold  water,  in  constipation,  292. 
in  vaginitis,  403. 
nasal,  671. 
of   bladder,    420,   421;    of   colon,    in   typhoid, 

699. 
saline,  in  athrepsia,  360;  in  diarrhoea,  277. 
Ischio-rectal  abscess,  332. 

Isolation,  in  diphtheria,  565,  618;  in  dysentery, 
283;  in  influenza,  476,  483;  in  measles, 
640;  in  mumps,  7-59;  in  pertussis,  3S9; 
in  scarlet  fever,  664;  in  syphilis,  724; 
in  varicella,  678;  in  variola,  685. 
ltching,_  in  scabies,  883;  in  scarlet  fever,  664. 
in  variola,  685. 

Jacket,  pneumonia,  461,  462. 

James's    apparatus    for    expanding    the    lung 

after  empyema,  470. 
Jaundice  (see  also  Icterus),  48,  381. 

catarrhal,  251. 
Jaw,  in  alveolar  abscess,  233. 

in  tetanus,  800. 

necrosis  of,  in  stomatitis  gangrenosa,  228. 

upper,  in  syphilis,  721. 
Joints,  diseases  of,  890. 

in  gonorrhoeal  infection,  402;  in  hnpmophilia. 
752;  in  meningitis,  820:  in  purpura  rheu- 
matica,  748;   in  rheumatism,  711. 

scrofulous,  519. 
Junket,  908. 
Just's  food,   202;  analysis  of,  202. 

Keller's- malt  soup,  170,  907;  in  athrepsia,  360. 


Keratitis,  in  measles,  639;   in  meningitis,  826. 
Kernig's  sign,  826. 
Kidney,  calculi  in,  420. 
congenital  cyst  of,  58. 
dilatation  of,  412. 
diseases  of,  405. 
htemorrhage  from,  417. 
inflammation  of,  406. 
in  new-born,  918;  in  pyelitis,  413;  in  scarlet 

fever,  656. 
position  of,  in  infancy,   405. 
sacculation  of,   412. 
Klebs-LoefHer  bacillus,  539,  541. 
in    diphtheritic    omphalitis,    33;    in   measles, 

636;  in  membranous  conjunctivitis,  Sfi3. 
smear  preparation,  544. 
stain  for,  929. 
Knee,    in    morbus    coxarius,    89S;    in    rachitis, 

342,  348. 
Knee-jerk  (see  Patellar  Reflexes). 

in  multiple  neuritis,  794. 
Knee-joint   disease,   901;    diagnosis,   901;   from 
rheumatism,     901;     etiology,     901;     path- 
ology,    901;     prognosis,    902;     symptoms, 
901;  treatment,  902. 
in  morbus  coxarius,  898;  in  rachitis,  342. 
Knock-knee,   in  rachitis,  342,  348. 
Koplik's  sign  in  measles,  632. 
Kyphosis,    in   Pott's   disease,   890;    In   rachitis, 
347. 

Lab-ferment,  236. 
action  of  on  milk,  62,  63. 

Laboratory  modification  of  milk,  173. 

Lachrymal  duct,  inflammation  of,  in  nasal 
catarrh,   420. 

Lactalbumiu,  121. 

Lactation,  massage  of  breasts  during,  95. 

Lactic  acid,  in  buttermilk,  183;  in  gastric 
contents,  915;  in  stomach,  237;  in  urine, 
183. 

Lactic  acid  bacillus,   183,  314. 

Lactoscope,  118. 

Lactose,  119. 

La  Grippe  (see  Influenza),  479. 

Lahmann's  vegetable  milk,  187. 

Laparotomy,  in  appendicitis,  318;  in  intestinal 
perforation,  697;  in  intussusception, 
325;  in  tuberculous  peritonitis,  392,  394. 

Laryngeal    spasm    in    bronchial    asthma,    4.55; 
in   rachitis,    346;    in   status   lymphaticus, 
753. 
recurring,  600. 

Laryngeal  stenosjs,  congenital,  56. 
in  diphtheria,  551,  572,  579;  in  retro-pharyn- 

geal  abscess,  443. 
intubation,   in  chronic,  592. 
specific,  following  intubation  and  decubitus, 
600. 

Laryngismus     stridulus,     following     broncho- 
pneumonia, 798;   typhoid,  798;  whooping- 
cough,  798. 
with    athrepsia,    798;    rachitis,    798;    tetany, 
798. 


964 


INDEX. 


Laryngitis,    complicating  measles,   63G. 
spasmodic,   444;    diagnosis  from   diphtheritic 
croup,     444;     predisposing    factors,     444; 
prognosis,    445;    treatment,    445;    emetics, 
447;    hypodermic   medication,    447;    inha- 
lations of  steam,  447. 
Larynx,   congenital  stenosis  of,   56. 
foreign  bodies  in,  447. 
granulomata  of,  889. 
growths  of  (see  Papillomata),  888. 
intubation  in,  593. 
in   diphtheria,  551,  581. 
tolerance  of,  for  intubation  tube,  593. 
tracheotomy  in  stenosis  of,  615. 
Lateral  curvature  of  the  spine,  897. 
Late  speaking,  3. 
Lavage    (see  Stomach-washing). 
Lecithin,  210. 

Leeches,    application    of    to    relieve    cerebral 
congestion,  512. 
in   convulsions,    783;    in   orchitis,   complicat- 
ing mumps,  758;  in  rheumatism,  744. 
Leffert's  nasal  syringe,  427. 
Lentigo,  876. 

Leptomeningitis   (see  Pachymeningitis),   833. 
Leucocytosis,  728. 
in   chorea,   729;   in  diphtheria,   548;   in  nerv- 
ous diseases,  729;  in  pneumonia,  508,  728; 
in  rachitis,  728;  in  scarlet  fever,  647. 
polynuclear,  increase  in  pus,  728,  730. 
Leucomain  poisoning,  750. 
Leucopnenia  in   typhoid,   696. 
Leukcemia,  735. 
blood   in,    735,   736;   diagnosis,    735;    etiology, 
735;    pathology,    735;    spleen,    735;    symp- 
toms, 735;  treatment,  736. 
lymphatics  form,  735. 
myelogenous  form,  735. 
splenic  form,  735. 
Lichen  tropicus,  875. 
Liebermann  phenol   test  for  formaldehyde   in 

milk,  913. 
Lien  mobilis,  386. 
Lienteric  stool,  229. 
Lime,  saccharated  solution  of,  1.30. 
salts,  in  cows'  milk,  127. 
water,  in  modification  of  cows'  milk,  129. 
Lingual  tonsil,  in  status  lymphaticus,  753. 
Lipoma,  887. 

Lips,  cyanosis  of,  in  broncho-pneumonia,  458. 
in    adenoid    vegetations,    438;    in    cretinism, 
760;   in  septic  diphtheria,  553. 
Lithaemia,    750;    diet    in,    751;     etiology,     750; 
symptoms,  750;  treatment,  751. 
urine  in,  751. 
Lithiasis,  appendicular,  316. 
Lithuria  (sec  LithEemia),  750. 
Liver,   amyloid  degeneration  of  (v/axy),  383. 
cirrhosis  of,  384. 
descended,  383. 
diseases  of,  381. 
displacement  of,  ,382,  383. 
in  constipation,  288. 


fatty,  383. 

focal  necrosis  of,  384. 
functional  disorders  of,  382. 
in   congenital   obliteration   of  bile-ducts,   35; 
in   diphtheria,   552;    in   gastro-duodenitis, 
251;    in    leukfemia,   735,    736;    in   malarial 
fever,  711;   in  pseudo-leukremic  anaemia, 
737;    in    scarlet    fever,    660;    in    tubercu- 
losis, acute,  530. 
spots   (see   Chloasma),   873. 
weight  of,  381. 
Lobar  pneumonia,  497. 
Lobular  pneumonia,  456. 

Local  antesthesia,   931;  by  injection  of  sterile 
water,  932. 
blood  letting,  938. 
remedies,  937. 
Lock-jaw  (see  Tetanus),  800. 
Loefller's   bacillus,  543. 
Lordotic  albuminuria,  416. 
Loss  of  speech  due  to  paralysis,  4. 

of  vision  due  to  pertussis,  489. 
Lumbago,  745. 

Lumbar   puncture,   823,    829;    amount   of    fluid 
to   be    withdrawn,   830;    anaesthesia,    828; 
needle  required,  829;  place  for  puncture, 
829. 
dry-tap  in,  830. 

in   convulsions,   783;    in   hydrocephalus,    817; 
in  meningitis,   tubercular,   822;   epidemic 
cerebro-spinal,  829. 
Lung,  at  term,  1. 

inflation  of,  44. 
auscultation  of,  450. 

cavities    of,    in    chronic    pulmonary    tuber- 
culosis, 536. 
compressed,  in  pleurisy  with  effusion,  466. 
cut  surface   of,   in   acute   pulmonary   tuber- 

losis,  536. 
gangrenous  infiltration  of,  228. 
in    broncho-pneumonia,    459;    in    diphtheria, 
553;     in     empyema,     467,    470;     in     lobar 
pneumonia,    497,    498;    in    scarlet    fever, 
660;   in  tuberculosis,  acute,  451;  in  wan- 
dering pneumonia,   499. 
percussion    of,    451;    points    in    examination 

of,  450. 
position   of,   450. 

transverse  section   of,   in  tuberculous  bron- 
cho-pneumonia, 537. 
Lymph  adenitis,  retro-pharyugeal,  442. 
Lymphatic   glands,    (Lymph   Nodes),    diseases 
of,  753. 
enlarged,  causing  torticollis,  747. 

in  anaesthesia,  931;  in  mumps,  758. 
in  diphtheria,  acute,  548;  local,  551;  in 
leukaemia,  735;  in  pseudo-leukaemic 
anaemia,  737;  in  retro-cesophageal  ab- 
scess, 234;  in  retro-pharyngeal  abscess, 
442;  in  tonsillitis,  432;  in  tuberculosis, 
acute,  530. 
Lymphocytes,   increase  of,   after  second   year, 


INDEX. 


965 


Lymphocytes  (concluded), 
in  diphtheria,  7:^9;  in  malaria,  729;  in  pneu- 
monia,  729;   in  scarlet  fever,  729;   in  ty- 
phoid, 729. 

MacEwen's  percussion  note,  775. 

Macrocephalus,   in   epilepsy,   802. 

MacTOcytes,  in  syphilis,  728. 

Mackenzie  tonsillotome,  436. 

Magendie  foramen,   in  hydrocephalus,   778. 

Malarial  fever,  706. 

diagnosis,    714;   differential,  714. 
pathology,    711;    blood    in,    711;    liver    in, 

711;   spleen  in,  711. 
Plasmodia  in,  707. 
prognosis,  715. 
symptoms,  714. 

treatment,  715;  quinine  in,  715. 
aestivo-autumnal,  709. 
double  tertian,  706. 
quartan,  708. 
quotidian,  706. 
tertian,  706. 
Malformations   of  the  rectum,   59. 

of  the  spinal  cord,  807. 

Malignant  endocarditis,  374. 

growth  in  bladder,  421. 

purpuric   fever    (see   Meningitis,    Epidemic), 
824. 
Malnutrition   (see  Athrepsia  Infantum),  356. 

in  chronic  gastritis,  252;  in  rachitis,  348. 
Malted  milk,  Horlick's,  196. 
Malt  extract,  in  summer  complaint,  155. 
Malt  soup,  167,  170,  907;  in  athrepsia,  360. 
Maltose,  238. 
Mammary  glands,  66. 
Management  of  woman's  nipples,  93. 
Mannaberg's  table  of  malarial  parasites,  713. 
Marasmic  thrombosis,   860. 
Marasmus    (see  Athrepsia   Infantum),    356. 
Marchand's  test  for  fat  in  milk,  117. 
Massage,  method  of  performing,  293. 
in   cerebral   paralysis,    839;    in    constipation, 

293;   in  spinal  paralysis,   813. 
of  breasts  during  lactation,  9b. 
vibratory,  293. 
-Mastitis  neonatorum,   50. 

Mastoid    disease,    in    otitis    media,    857:    oper- 
ation,    857;     facial     paralysis     following, 
859. 
Masturbation,  796;  causes,  796;  prognosis,  797: 

symptoms,   796;    treatment,    797. 
Materna  home  milk  modifier,   150. 
.Matzoon  (see  Zoolak),  209. 
Measles,  628. 

bacteriology,  628. 

complications,    635;    broncho-pneumonia, 
636;   croup,    640;    diarrhcra,   640;   diph- 
theria, 640;  empyema,  6:59;  eyes,   G39; 
otitis,   6.38. 
diagnosis,   640;   from  drug  eruption,   640; 

from  influenza,  640;  variola,  683. 
etiology,   628. 
immunity,  639. 


incubation  period,  625. 
mortality,  628. 

pathology,  628. 
prognosis,   640. 
sequels,     tuberculosis,    519. 
symptoms,  630;  desquamation,  633;  erup- 
tion, 630,  632;  enanthem,  630. 
treatment,  640;  convalescence,  633;  isola- 
tion, 640. 
German,  622. 

haemorrhagic  form,  634. 
malignant  form,  633. 
mild  form,  633. 
relapsing  form,  633. 
Meat  juice,  211. 
Meckel's  diverticulum,  35. 
Meconium,   262. 

Medication,  points  concerning,  9:J6. 
hypodermic,  943,  944. 
local,  937. 
rectal,  939. 
Meigs's  food,  209. 
Melaena,  38. 
Mellin's   food,   201;   analysis,   202;   formula  for 

preparing,  202. 
Membrane,   in  d.phtheria,  551,  558. 
Membranous   conjunctivitis,   863. 
Meningitis,  cerebro-spinal,  824. 
bacteriology,  824. 
diagnosis,  826. 
etiology,   824. 
lumbar  puncture  in,  829. 
mortality  in,  825. 
pathology,   824. 
prognosis,  831. 
serum,     831;     symptoms,     825;     eruption, 

826;  Kernig's  sign,  826. 
treatment,    831;    intracranial    injections, 
832;  intra-spinal   injections,  832. 
tubercular,  819. 

bacteriology,  819. 

course,  821. 

diagnosis,  S22. 

etiology.    819. 

lumbar  puncture  in,  823. 

pathology,  819. 

symptoms,     822;      Babinskl     reflex,     823; 

Tache  cerebrate,  823. 
treatment,  823. 
Meningococcus,  824;  stain  for,  929. 
Menstruation,   effect  of  on  woman's  milk,  61, 
66,  82. 
in  chlorosis,   738. 
pra>cox,  404. 
vicarious,  404. 
.Mental  faculties,  2. 

Mercury,    administration   of,    to   chlldnti.   22S, 
940. 
in   treatment  of  syphilis,  725. 
Metabolism,  242. 

Meteorismua  (see  Intestinal  Colic),  296. 
MIcrocephalus,  craniectomy  In,  839. 
fontanel  in,  770, 


966 


INDKX. 


Microcephalus  (conelucied). 
in    chronic   hydrocephalus,    815;    in   epilepsy, 
802. 
Micrococcus  catarrhalis,   824,  827. 
Microcytes,  in  syphilis,  728. 
Micro-orgauisms   (see  Bacteria). 
Middle-ear  abscess,  causing  abscess  of  brain, 

843. 
Migraine,  785. 

Miliaria  papulosa,  875 ;  rubra,  876. 
Miliary     tuberculosis     (see     Acute     Tubercu- 
losis),  516. 
Milk,  Bulgarian,  183. 
cows',  99. 

addition  of  alkalies  to,  129. 
adulteration    of,    912:    formaldehyde    in, 

912;  tests  for,  912. 
analyses  of,  99,  100. 
a    possible    factor    in    the    causation    of 

scarlet  fever,  643. 
certified,  in  New  York  City,  103. 
chemistry  of,  albuminoids,  125;  enzymes, 
127;    fat,    116;   milk-sugar   or  lactose, 
119;  proteids,   121;   salts,   126;   starch, 
127. 
composition  of,  99. 
condensed,   191. 
diluents  of,  134. 
fresh,  raw,  115. 
home  modification  of,  139. 
idiosyncrasies,  168. 
laboratory  modification   of,   173. 
pasteurization  of,  164,  909. 
pasteurizer  or  sterilizer,  167. 
predigested  or  peptonized,  910. 
raw,   111,    113. 
sterilization  of,   159;   changes  caused  by, 

159,  160. 
sterilizers,   164,   167. 
top,  137. 
tuberculous    infection    through,    105,    115, 

116. 
undiluted,  as  a  food  for  infants,  115. 
variation  of,  99. 
woman's   (see  Breast  Milk),  64. 

analyses  of,  65,  120;  comparative,  67,  70, 

71. 
apparatus  for  examining,  66,  68. 
colostrum  of,  64. 

oomposition   of,    65;    compared   with    dif- 
ferent   infant   foods,    196. 
conditions    affecting   composition    of,    66; 
alcoholic     drinks,     79;     antemia,     75; 
diet,    77,    97;     drugs,    73;    menstrua- 
tion, 75. 
nervous  irritability,  73. 
deterioration  in,   87. 
examination  of,  microscopical,  68. 
enzymes,   diastatic  in,  69. 
fat,  to  decrease,  87;  to  increase,  87. 
how  to  increase  quantity  of,  73,  73. 
immunity  conferred  by,  69,  516,  566. 
method  of  changing  ingredients  in,  87. 
to  preser\  e,  70. 


proteids,  87;  to  decrease,  87;  to  increase, 

87. 
reaction  of,  69. 
scanty,  72. 
specific  gravity,  66. 
specimen    for    examination,    67;    how    to 

procure,  67. 
variations  in,  84. 
Milk  of  magnesia,  141,  299. 

Milk  substitutes,   Backhaus',  190;   cereal,  197; 
Gaertner    mother,    188;    humanized,    203, 
909;  Lahmann's  vegetable,  187. 
Milk-sugar  or  lactose,  119. 
Milk-test,  Babcock's,  117. 
Mitchell's   milk   modifying   gauge,    152. 
Mixed  feeding,  72,  90;  additional  foods  during 

nursing  period,  76. 
Mobius'sche  kernschwund   (see  Pleuroplegia), 

839. 
Modified    milk    from    milk    laboratories,    173; 

prescription  formulse,  173. 
Modified  small-pox  (see  Varioloid),  685. 
Monarthritis,  402. 

in  gonorrhceal  vaginitis,  402. 
Mongolian  idiocy,  846. 
Monoplegia,    htemorrhage    into    sub-arachnoid 

space,   causing,  778. 
Morbilli    (see  Measles),   628. 
Morbus  coxarius,  898. 
Morbus  maculosus  Werlhofii,  748. 
Mortality,  in  cerebro-spinal  meningitis,  824. 
in  consumption,  525,  526. 
in  diarrhoeal  diseases,  304,  305. 
in  diphtheria,  541;  and  croup,  540. 
in  diphtheria  treated  with  and  without  anti- 
toxin, 578. 
in  infectious  diseases,  475,  478. 
in    intubated    cases    of   diphtheria,    579,    580, 

581,  583. 
in  measles  and  complications,  629,  634. 
in  pulmonary  tuberculosis,  524. 
in  small-pox,   680. 

in  tubercular  diseases,  527,  528,  529. 
in   whooping-cough,   486. 
of  babies  raised  in  incubators,  26. 
Morton's  fluid,  818. 
Mosite  in  diabetes  insipidus,  416. 
Mosquera's   beef,   meal,   206;  analysis   of,   206; 

jelly,   207. 
Motor  function  of  the  stomach,  916. 
Mouth-breathing,     a     symptom   of     adsnoids, 

438,  4-39;  of  enlarged  tonsils,  435. 
Mouth,   condylomata  of,  in  syphilis,  720. 
diseases  of,  222. 

hemorrhage  from,  in  syphilis,  719. 
hygiene  of,  16. 

in    adenoid    vegetations,    438;    in    Bednar's 
aphth£E,  225;  in  stomatitis  aphthosa,  224; 
in  stomatitis  catarrhalis,   223;   in  stoma- 
titis mycosa,  225. 
Movable  spleen,  386. 

Mucous    membrane,    conjunctival,    in    gastro- 
duodenitis,  250. 
of  mouth,  at  birth,  236;   in  measles,  630. 


INDEX. 


967 


Mucous  membrane  (concluded) 

of  pharynx,  in  scarlet  fever,  652. 

of  stomach,  236;  in  gastric  catarrh,  243. 

of    trachea    and    bronchi,    in    broncho-pneu- 
monia, 457. 
Mucous  disease,  300. 

in  stools,  264. 
Muguet  (see  Stomatitis  Mycosa),  225. 
Multiple    neuritis,    793;    causes,    794;    course, 
795;  symptoms  and  diagnosis,  794;  treat- 
ment, 795. 
Mumps,  757. 

complications,  758;  orchitis,  758. 

diagnosis,   757;   differential,    758;    from   diph- 
theria, 758. 

etiology,  757;  isolation,  759. 

period  of  incubation,  757;  prognosis,  758. 

symptoms,  757. 

treatment,  758. 
Murmurs,  366. 

anaemic,  367. 

cardiac,  364,   366. 

cerebral   blowing,   369. 

diastolic,  367. 

pericardial,  368. 

systolic,  366;   in  chlorosis,  738. 

venous,  368;  in  chlorosis,  738. 

vesicular,  in  bronchial  asthma,  455. 
Muscles,    atrophy    of,    in    acute  myelitis,    806; 
in  poliomyelitis,  810,  812. 

fatty  infiltration  of,   in  pseudo-hypertrophic 
paralysis,  840. 

flabby,  in  rachitis,  348. 

wasting  of,  in  scurvy,  340. 
Muscular  atrophy,    in   acute  myelitis,   806;    in 
poliomyelitis,  810,  814. 

in  pseudo-hypertrophic  paralysis,  840. 
Muscular,  pseudo-hypertrophy,  840. 

rheumatism,  745. 

spasms,   in  rachitis,  346. 
Mustard  foot  bath,  641;  in  convulsions,   7s.i. 

plasters,  938. 
Myalgia,  745. 

Myelitis,  acute,  805;  diagnosis,  806;  etiology, 
805;  pathology,  805;  prognosis,  807; 
symptoms,  806;  treatment,  807. 

chronic,  807. 
Myelocytes,  728. 

in    diphtheria,    728;    in    Icuktem^a.    736;    in 
pneumonia,    728;    in   syphilis,   728. 
Myocarditis,   379. 

causes,  379. 

complicating  diphtheria,  559. 

diagnosis,  379. 

pathology,  379. 

prognosis,   380. 

symptoms,  379. 

treatment,  380. 
Myxtrdcnia  (sec  Cretinism),  760. 
MyxcEdematous  idiocy   (see  Cretinism),  760. 

Naevus,  878. 

Nails,  in  secondary  ansmia,  734;  in  syphilis, 
719. 


Xasal   catarrh,    425;    etiology,    425;    symptoms, 
425;  treatment,  426. 
a  symptom  of  measles,  426;   of  syphilis, 

719. 
causing  otitis,  426. 
discharge,  in  diphtheria,  551,  553. 
douching,  428,  671. 
syringe,  427. 
Naso-pharyngeal  catarrh,  428;  in  syphilis,  713. 
Navel,  dangers  in  careless  handling  of,  33. 

management  of,  16. 
Necrosis  of  liver,  in  malarial  fever,  710. 
of     jaw-bone,      following     stomatitis      gan- 
grenosa, 228. 
Neck,  in  cretinism,  760. 
rigidity  of,   in  typhoid,  694. 
stiff,   in  torticollis,  746. 
Neonatorum    (see   also   New-born   Infant), 
hsemoglobinuria,  50. 
icterus,  48;  urine  in,  918. 
mastitis,  50. 
ophthalmia,  863. 
pemphigus,  52. 
sclerema,   49. 
Nephritis,  acute,  405. 

as  a  complication,  407. 
blood  in,  406. 

complicating   influenza,   482. 
etiology,   405. 
pathology,  406. 
prognosis,   407. 
symptoms,  407. 
treatment,   408. 
urine  in,  406,  407,  919. 
acute  glomerulo,   405. 
catarrhal,  in  scarlet  fever,  656. 
chronic  interstitial,   from  increased   urinary 

pressure,  412. 
diffuse,   in  diphtheria,  552,  560. 
post-scarlatinal,  657. 
secondary,  408. 
Nerve,    pneumogastric,    in    dyspeptic    asthma, 

259. 
Nerves,  in  multiple  neuritis,  793. 

vasomotor,  causing  asthmatic  attacks,  455. 
Nervous    impressions,    effect    of,    on    woman's 

milk,   73. 
Nervous  system,  diseases  of,  775. 

in  typhoid,  694. 
Nestle's  food,   195;  analysis  of,  196. 

in  acute  milk  infection,  156. 
Nettle  rash  (see  Urticaria),  871. 
Neuralgia,   interstitial,    296. 
complicating  variola,  685. 
Neuritis,   multiple,   793. 
causes,   794. 

complicating  influenza,  482. 
course  and  prognosis,   795. 
symptoms  and  diagnosis,  794. 
treatment,  795. 
peripheral,   793. 
New-born,    abnormalities   of,    .53;    acute   fatty 
degeneration     of,     50:     asphyxia    of,    42; 
bleeding     In,     720;     BuhTs     disease,     50: 


968 


INDEX. 


New-born  (concluded). 

diphtheria  in,  33;  erysipelas  in,  51;  frac- 
ture in,  40;  haemoglobiuuria  (Winckel's 
disease),  50;  hsemorrhage,  gastro-intes- 
tinal,  38;  into  adrenal  glands,  77-1;  um- 
bilical, 33,  38;  ichthyosis,  46;  icterus,  49; 
inflation  of  lungs  in,  44;  malformations 
of,  53;  mastitis,  50;  paralysis  of,  40,  842; 
pemphigus  in,  52;  peritonitis  in,  52;  scle- 
rema, 49;  syphilis  in,  716;  tuberculosis 
in,  52,  517;  typhoid  in,  691. 
Night   cough,  448. 

Night-sweats,   in   tuberculosis,   535. 
Night-terrors  (see  Pavor  Nocturnus),  795. 
Nipple,   anticolic,   158;   sterilizer,   159. 
Nipple-shield,   94. 
Nipples  for  bottle  feeding,  158. 
harelip,  54. 

management  of  woman's,   93;   sore,   93;  ten- 
der, 94;   to  harden,  94. 
Nitrous  oxide  and  ether,  930. 
Nodding-spasm  (see  Spasmus  Nutans),  785. 
Nodes,   lymph   (see  Lymph  Nodes). 
Nodules,  subcutaneous  tendinous,  in  rheuma- 
tism, 742. 
tubercular,  819,  82(). 
Noma  (see  Stomatitis  Gangrenosa),  227. 
Nose-bleed  (see  also  Epistaxis) ;  in  diphtheria, 

559;  in  syphilis,  719. 
Nose,  discharge  from,   in  diphtheria,   551,  553. 
diseases  of,  425. 
foreign  bodies  in,  430. 
haemorrhage   from,    in   exophthalmic   goiter, 

772;  in  syphilis,  719. 
in  adenoid  vegetations,  438. 
in  cretinism,  760. 
picking  of,  328. 
Nurse  (see  also  Wet-Nurse),  21. 
Nursery,   furniture  in,   21 ;   light  of,  21 ;   loca- 
tion of,  20;  method  of  heating,  21;  ven- 
tilation of,  20. 
Nursing  (see  also  Feeding),  71. 
length  of  time  for,  72. 
prolonged,   causing  rachitis,   314. 
schedule  for,  from  birth  to  one  year,  71. 
Nursing-bottles,   157;   care  of,   157. 
Nutrient  enemata  (sec  Rectal  Feeding). 
Nutrients  and  stimulants,  209. 
Nutritive  tonics,   chemical  analysis  of,  208. 
Nutritive  value  of  eggs,  210. 
Nutrol,  205. 

Nystagmus,  complicating  spasmus  nutans,  785. 
in  hereditary  ataxy,  809. 

Oatmeal  bath,  18;  in  eczema,  870. 
•water,  906. 

Obliteration  of  the  bile-ducts,   congenital,   35. 

Obstetrical  paralysis,  40. 

O'Dwyer's  method  of  intubation,  586. 

CEdema,  in  erysipelas,  704;  in  variola,  685. 
of  ankle,  738;   of  cheek,   in  stomatitis  gan- 
grenosa,   228;    of   eyelids,    in    thrombosis 
of  cerebral  sinuses,  860;  of  feet,  in  mye- 
litiB,  806;  of  glottis,  in  scarlet  fever,  671; 


of  larynx,  659;   of  lips,   in  myelitis,  806; 
of  pia  mater,  659;  of  scalp,  860. 
CEsophagitis,  acute,  234. 

chronic  or  diphtheritic,  234. 
oesophagus,  foreign  bodies  in,  235. 
CEgophony,  465,   467. 
Oiled-silk    jacket     (sec     Pneumonia     Jacket), 

514;   how  to  make,   462. 
Oil,  enema,  in  acute  peritonitis,  389. 

internally  in  chronic  constipation,   290. 
Omphalitis,  diphtheritic,  33. 

septic,  34. 
Onanism  (see  Masturbation),  706. 
Omphalomesenteric  duct,  34. 
Ophthalmia,   granular,   861. 

neonatorum,  863. 

pneuniococcus,   862. 

purulent,  863. 
Ophthalmo-tuberculin   reaction,   533. 
Opisthotonos,  hysterical,  791. 

in  meningitis,  826. 
Orange  juice  in  scurvy,  340. 
Orchitis,  400. 

in  mumps,  758. 
Orthostatic  albuminuria,  416. 
Osteoclasis  in  rachitis,  355. 
Osteomyelitis   (see  Arthritis,   Acute),  903. 
Osteotomy  in  rachitis,  355. 
Osteitis,   infectious,   903. 

of  the  femur,  901;  of  the  tibia,  901. 
Otitis,  complicating  diphtheria,  577;  influenza, 
482;    measles,    C38;    rhinitis,    426;    scarlet 
fever,  653,-  667;  typhoid,  638;  variola,  685. 
Otitis  media,    acute  catarrhal,   854. 

bacteriology,  854. 

diagnosis,  856. 

etiology,  854. 

pathology,  855. 

prognosis,   856. 

symptoms,  855. 

treatment,   856;   general,  856;   operative,   857; 
prophylactic,  856. 
Oxygen,    in   dyspnoea   and   cyanosis,    513. 
Oxyuris  vermicularis,  329. 
Ozsena,  a  sequela  to  scarlet  fever,  661. 

Pachymeningitis,  acute,  833. 
chronic,  833;  diagnosis,  833;  differential,  834; 
pathology,     833;    prognosis,     834;     symp- 
toms,  833;   treatment,  834. 
ihfemorrhagic,  833. 
non-haem.orrhagic,  833. 
Pack,   cold,  485;   hot,  666. 
Palate,  cleft,  54. 

feeding  in,  54;  gavage  in,  54. 
in    Bednar's   aphthae,    225;    in    measles,    630; 
in    purpura    haemorrhagica,    748;    in    ru- 
bella, 623. 
paralysis  of,  in  diphtheria,  562. 
Pallor  of  the  skin,  180. 

Palpation  of  the  liver,  381;  of  the  spleen,  386. 
Palsy  (see  Paralysis). 

acute  spinal,  from  acute  cerebral,  810. 
Paludal  fever  (see  Malarial  Fever),  706. 


INDEX. 


969 


Pancreas,  diseases  of,  387. 
function  of,  387. 
in  syphilis,  719. 
position  of,  387. 
Pancreatic  juice,  236. 
Panopepton,  207;  analysis  of,  207. 
Panophthalmitis,  in  meningitis,  826. 
Papillomata,  888. 
Paracentesis,   in  otitis,  668. 
Paralysis,  following  pertussis,  489,  8-34; 

in    hereditary    ataxy,    809;    in    multiple 
neuritis,   794;    in    Pott's   disease,    893; 
in    thrombosis    of    cerebral    sinuses, 
860. 
of  vocal  cords,  following  intubation,  607, 
611. 
Bell's,  842. 
cerebral,  834. 

acquired  after  labor,  835. 
course,  838. 

diagnosis,  836;  differential,  838;  from  in- 
fantile spinal  paralysis,  838. 
etiology,   834. 

occuring  during  labor,  835. 
of  intra-uterine  onset,  835. 
pathology,  834. 
symptoms,   836. 

treatment,  8.39;  operative,  839. 
facial,  842. 

following  mastoid  operation,   859;    retro- 
pharyngeal abscess,  842. 
in  new-born,  842. 
Infantile  spinal,   809. 

diagnosis,    812;    from   cerebral   paralysis, 

838. 
etiology,   809. 
pathology,  809. 
prognosis,  812. 
symptoms,  810. 

treatment,   812;   orthopaedic,   813. 
post-diphtheritic,  561,  577. 
frequency  of,  562. 

of   bladder,    562;    of   extremities,    563;   of 
palate,  562;  of  rectum,  562;  o£  trunk, 
562. 
Paraphimosis,   398. 

Paraplegia  (see  Paralysis,   Cerebral),  834. 
Parasitic   stomatitis   (see   Stomatitis   Mycosa), 

225. 
Parotitis,  specific  (see  Mumps),  757. 
Pasteurization  of  cows'  milit,  164,  909. 
Patellar   reflexes,    552;    in    cerebral    paralysis, 
836;   in  meningitis,  826;   in   pseudohyper- 
trophic  paralysis,   842. 
Patent  foods.  193. 
Pavor  nocturnus,  795. 
Pediculosis,  875. 
Peliosis  rheumatica,  748. 
Pelvis,  in  congenital  dislocation  of  hips,   000; 

in  rachitis,  348. 
Pemphigus,   chronic,   878. 
in  syphilis,  719. 
neonatorum,  52. 
Pendulous  belly,  In  rachitis,  350. 


Pepsin,  236. 
function   of,    237,   238. 
in  gastric  contents,  916. 
Peptogenic  milk  powder,  203;  analysis  of,  203. 
Peptone,  in  gastric  contents,  916. 
Peptonized  milk,   910. 
Percussion  of  the  lung,  451. 
of  the  skull,  775. 
resonance,   451. 
Pericardial  murmurs,  368. 
Pericarditis,  375. 

bacteriology,  375. 
etiology,   375. 

complicating     diphtheria,     559;     rheuma- 
tism, 743;  typhoid,  698. 
pathology,   376. 
physical  signs,  376. 
prognosis,   377. 

symptoms  and  diagnosis,  376. 
treatment,     377;     aspiration    of    pericar- 
dium, 377. 
chronic,  with  adhesions,  377;  diagnosis,  377; 
symptoms,  377;   treatment,  378. 
Pericardium,  aspiration  of,  377. 

tuberculosis  of,  378. 
Perinephritis,   409;   bacteriology,  409;  etiology, 
409;      pathology,      409;      prognosis      and 
course,    410;    symptoms,    410;    treatment, 
410. 
blood  in,  410. 

diagnosis   from   hip-joint  disease,   410. 
simulating  Pott's  disease,   410;   sciatica,  410. 
Perineum,  in  imperforate  anus,  59. 
Periosteum,  in  rachitis,  342,  343. 
Periostitis,     complicating    stomatitis    gangre- 
nosa, 228. 
Peripheral    neuritis    (see    Multiple    Neuritis), 

793. 
Peritoneum,   diseases  of,   388. 
Peritonitis,  acute,  388. 
bacteriology,    388;    etiology,    .388;    pathology, 
388;      prognosis,      389;      symptoms,      388; 
treatment,    389;    operative,   389. 
ascites  due  to,  393. 

complicating  rheumatism,   742;   typhoid,  698. 
in  the  new-born,  52. 
chronic,  389. 
fibrinous,  388. 
non-tuberculous,  389. 
purulent,  388. 
serous,  388. 
tuberculous,   390. 
fibrous  form,  390. 

diagnosis,     390;    symptoms,    390;     prognosis, 
392;     treatment,     .392;     laparotomy,     392; 
light,  392;  serum,  .392. 
Peritonsillar  abscess,   433. 

resembling  diphtheria,  558. 
Perityphlitis   (see  Appendic'tis),   315. 

tuberculous,  519. 
Pernicious  anaemia,  734. 
Perspiration  (see  also  Sweating),   12. 
Pertussis,  486. 
bacteriology,  487. 


070 


INDEX. 


Pertussis  (concluded), 
complications,    488;    aphasia,    489;    broncho- 
pneumonia,   488;    cerebral    haemorrhage 
489;   convulsions,   489;   diabetes   mellitus 
489;     emphysema,     489;     empyema,     489 
epistaxis,  489;  hernia,  489;  loss  of  vision 
489;    nephritis,    489;    paralysis,    489,    834 
pleurisy,    489;    prolapse    of    rectum,    489 
scarlet  fever,  652;  strabismus,  489. 
course,  489. 
diagnosis,  488. 
etiology,   486. 
pathology,   487. 
prognosis,    489. 

sequelae,    tetany,    798;   tuberculosis,   519. 
stages,   catarrhal,   487;   of  decline,   488;   par- 
oxysmal, or  whooping,  488. 
symptoms,  487. 
treatment,  489. 
Petechia,  in  hemophilia,  752;  in  purpura,  747. 
Peyer's  patches,  260. 

in  athrepsia,  357;  in  typhoid,  690. 
Pharyngeal  catarrh,  causing  spasmodic  croup, 

444. 
Pharyngitis,     granular,     Plate    XIV;     in     in- 
fluenza, 481. 
Pharynx,   in   local   diphtheria,   551;   in  scarlet 
fever,   647;    in   septic   diphtheria,   553;    in 
stomatitis  aphthosa,  224;  mycosa,  225. 
Phimosis,  397;  symptoms,  398;  treatment,  398; 
operative,  398. 
causing   chorea,    398;    night-terrors    and    in- 
somnia,  398. 
Phlegmonous    tonsillitis,    433;    symptoms,   433; 

treatment,   434. 
Phlorogluoin    test   for   formaldehyde   in   milk, 

912. 
Phlyctenular  conjunctivitis,  868. 
Phosphorus,   in  rachitis,  353. 
Photophobia,     in     cerebro-spinal     meningitis, 

826;   in  influenza,  482;   in  measles,  630. 
Phthisis  (see  Pulmonary  Tuberculosis),  535. 

pulmonis,  mortality  in,  524. 
Physical   examination  of  heart,   363. 
of   lungs,   450;    auscultation,    450;    breathing, 
451;   percussion   resonance,   451;    rhythm, 
4.51;  vocal  resonance,  451. 
Physical    signs,    in    empyema,    467;    in    lobar 
pneumonia,  506,  507,  .509;  in  pleurisy  with 
effusion,  465. 
Pia  mater,  blood-vessels  of,  778. 
closure  of,  in  hydrocephalus,  778. 
in  tubercular  meningitis,  819. 
Pigeon-hreast  (see  Prominent  Sternum),   57. 

in  rachitis,  342,  346. 
Pigmentary  nacvus,  878. 
Pinworms,  329. 
Pink  eye,  862. 
Plasmodium  malarise,  706. 
Plasmon,  200. 
Pleura,  diseases  of,  4.50. 
effusion  into,  465. 

inflammation   of,   in   pleuro-pneumonia,   501; 
in  scarlet  fever,  660. 


swollen,   in   dry  pleurisy,   463. 
Pleurisy,  463. 

complicating    diphtheria,    559;    pertussis, 

489;  rheumatism,  742. 
diagnosis,   464. 
pathology,   463. 
prognosis,  464. 
symptoms,   4G3;    cough,   463. 
treatment,  464. 
dry,  463. 
purulent,  466. 
with  effusion,  464. 
bacteriology,    464. 

diagnosis,  465;  exploratory  puncture,  465. 
pathology,  464. 
symptoms,     465;     cough,     465;     physical 

signs,  465. 
treatment,  466;  diet,  466. 
Pleuritis  exudativa,   464. 
Pleurodynia,  745. 
Pleuroplegia,  839. 
Pleuropneumonia,  501. 
Pleurothotonos,   in  pericarditis,  376. 
Pneumococcus,     in     broncho-pneumonia,     457; 
in  empyema,  467;  in  follicular  tonsillitis, 
432;   in  measles,   638;   in  meningitis,  824; 
in    perinephritis,    409;    in    pleurisy    with 
effusion,  464;  in  pleuro-pneumonia,  501. 
ophthalmia,  862. 
Pneumo-gastric     disturbance,     causing     asth- 
matic attacks,  259,   455. 
Pneumonia    (see    Broncho-pneumonia), 
abortive,  499. 
catarrhal,  456. 
cerebral,  502. 
gastric,  499. 
lobar,  497. 

bacteriology,  497. 
course,  506. 

etiology,  497;  age,  497;  lobe  affected,  497. 
pathology,    499. 

symptoms,    500;    blood,    506;    pulse,    507; 
ratio  of  pulse   and  respirations,   506; 
relapse,    509;    respirations,    507;    tem- 
perature,   507;    crisis,    507,    508;    pro- 
crisis,   508;    urine,   508. 
treatment,    510;    antipyretics,    511;    feed- 
ing,  514;   isolation,   510;   oxygen,   513; 
stimulants,   513. 
lobular,  497. 
migrans,  499. 
pleuro,  501. 

bacteriology,  .501. 
pathology,  501. 
prognosis,  502. 
symptoms,  501. 
treatment,  502. 
tuberculous,  514. 

cavities,  514;  course,  515. 
chronic  type,  515. 
rapid  type,  515. 
wandering,  499. 
Pneumonia  jacket,  461. 
Pock,  in  varicella,  676. 


INDEX. 


971 


Poikilocytosis,   in  syphilis,  728. 
Poisons  (see  also  Toxins), 
causing  toxic  multiple  neuritis,  79-t. 
elimination  of,  277. 
Poliomyelitis  (see  Paralysis,  Infantile  Spinal), 
809. 
acute    anterior,    from    post-diphtheritic    pa- 
ralysis, 563. 
Polyarthritis   (see  Rheumatism),  740. 
Polydipsia  (see  Third,  Excessive). 
Polyneuritis  (see  Multiple  Neuritis),  793. 
Polynuclear    leucocytes,    increase    of,    in    pus, 
730. 
in  infectious  diseases,  728. 
Polymorphonuclear    cells,    in    erysipelas,    728; 
in    diphtheria,    728;    in    pneumonia,    728; 
in  scarlet  fever,  728. 
Polypus,   umbilical,   34. 
Polyuria,  416;   in  diabetes  mellitus,   419. 
Porencephaly,  818. 
Pot-belly     in     rachitis     (see     also     Pendulous 

Belly),  260. 
Post-operative    palsy    (see    Facial    Paralysis), 

842. 
Potfs  disease,  890. 
bacteriology,   891. 
complications,    893;    abscess,    893;    paralysis, 

893. 
differential   diagnosis   from   rachitis,   355. 
etiology,  890. 

pathology,  891;  anatomical  landmarks,  891. 
prognosis,  895. 

symptoms,  892;  of  lower  region,  892;  of  mid- 
dle region,  893;  of  upper  region,  893. 
treatment,   896. 
Poultices,    flax-seed,    in    retro-pharyngeal    ab- 
scess,   443;     in    tonsillitis,    430;    how    to 
make,  937. 
ginger,  938. 
Powders,     dusting,     678;     talcum,     17;     velvet 

skin,  17. 
Precordia,   prominence  of,  364. 
Predigested  milk,   910. 

Pregnancy,  effect  of  on   nursing  infant,  90. 
Premature  infants,  24. 
method  of  feeding,  28;  artificial  feeding,  30. 
mortality  of,  25. 
prognosis,  31. 
serum  injections,  31. 
weight,  31. 
Prepuce,  adherent,  397. 

tight,  causing  enuresis,  423. 
Prescriptions   for  various  diseases,   941. 
Pre-tubercular  anaemia,  .530. 
Priapism,  in  phimosis,  397. 
Prickly  heat,  875. 
Procrisis,    in   pneumonia,   .508. 
Proctitis,  croupous,  332. 
simple  catarrhal,  ."31. 
ulcerative,   332. 
Prolapse  of  rectum,  following  pertussis,  489. 

in  diseases  of  the  bladder,   414,   420. 
Prolapsus    ani,    333;     causes,    333;     diagnosis, 
333;   treatment,  333. 


Prominent  sternum,  57. 
Propeptont  in  gastric  contents,  916. 
Prophylaxis  in  diphtheria,  564. 
Proprietary  infant  foods,  193. 
Proteid    indigestion,    causing    colic    and    con- 
stipation,  96. 
Proteids,  function  of,  in  diet,  121. 
in  cows'  milk,  121. 

in  excess,  causing  colic,  297. 
split,  122. 
in  woman's  milk,  86. 

determination   of,    123. 
to  increase,  87. 
Woodward's  burette  for  estimating,   124. 
Protrusion  of  ears,  56. 
Prune-water,   147. 
Pseudo-appendicitis,  319. 
Pseudo-diphtheria,  619. 
age  and  mortality  in,  620. 
bacteriology,  619. 
Pseudo-hypertrophic  paralysis,  840. 
Pseudo-leukasmic   anaemia,   736. 
etiology,   736. 

pathology,   736:  blood,   737;   spleen,  737. 
prognosis,  737. 
treatment,   737. 
Pseudo-paralysis,    in  scurvy,   337;   in  syphilis, 

723. 
Pseudo-pertussis,  448. 
Psoriasis,   873. 

Ptosis  in  thrombosis  of  cerebral   sinuses,  860. 
Ptyalin,   function  of,  238. 

Pulmonary    artery,    thrombosis    of,    in    diph- 
theria, 559. 
gangrene,  462. 
gymnastics,   23. 

in  empyema,  470;  in  tuberculosis,  535. 
stenosis,   369;   prognosis,  370. 
tuberculosis,  535. 
Pulse,   in  diagnosis,   306. 

of  high  tension,  363:  of  low  tension,  363. 
Pulse-rate,  asleep,  10;  awake,  10. 
in  bronchial  asthma,  455;  in  bronchitis,  4.33; 
in  broncho-pneumonia,  4.58;  in  diagnosis, 
10;     in     diphtheria,     552,     553;    in     lobar 
pneumonia,   506. 
Pulsus   paradoxus,   366. 
Pump,  breast,  95. 
Pupils,  as  diagnostic  aid,  12. 
in  cerebro-spinal  meningitis,  826;  in  chorea, 
788;   in   insolation.    851;    in    myelitis,   806; 
in  pachymeningitis,  833. 
Purpura,  747. 
complicating  rheumatism,  742. 
haemorrhagica,  748. 
diagnosis  from  scurvy,  748. 
rheumatica,  748. 
Purulent  ophthalmia,  863. 
pleurisy,  466. 
synovitis,  acute,  903. 
Pus  corpuscles  in   urine  from  a  case  of  post- 
scarlatinal nephritis,  6.58. 
Pya?mia,    complicating   measles,   639;   typhoid, 
698. 


972 


INDEX. 


Pyaemia  (concluded) 

in  acute  arthritis,  903. 
Pyelitis,  411. 

causes,  411. 

diet  in,  413. 

in  gonorrhoeal  infections,  402. 

pathology,  412. 

prognosis,  413. 

treatment,  413. 
Pyelo-nephritis  (see  Pyelitis),  411. 
Pylorus,  spasm  of,  248. 

Pyuria,    415;    in    colicystitis,    419;    in    pyclif.s, 
412. 

Quartan  intermittent  fever,  708. 
Quincke's  lumbar  puncture,  827. 
Quinsy,  433. 

resembling    diphtheritic    tonsillitis,    554. 
Quotidian   intermittent  fever,   707. 

Race,  influence  of,  upon  tuberculosis,  525. 
Rachitis,  341. 
causes,  344. 
course,  351. 
deformities  of,  347. 
diagnosis,   351;   differential,  351;  from  Pott's 

disease,   355. 
diet  in,  352. 

laryngeal   stenosis   in,   603. 
prognosis,  351. 
prophylaxis,   351. 

symptoms,  346;  blood  in,  728;  teeth,  345. 
tetany  in,  798. 

treatment,    351;    dietetic,    352;    hygienic,    351; 
medicinal,  352;  surgical,  355;  of  deformi- 
ties, 353;   kyphosis,  354. 
Ranula,    232;    character,    233;    symptoms,    23;^.; 

treatment,  233. 
Rashes   (see  Eruptions). 
Raw  milk.  111,  113,  115. 
Raynaud's  disease,  883. 
Reaction   of   degeneration,   779. 
in  acute  myelitis,  806;  in  acute  poliomyelitis, 
811;  in  multiple  neuritis,   791;   in  obstet- 
rical paralysis,  41. 
of  human  milk,  69. 
Rectal  feeding  in   bronchitis,  454;   in  cerebro- 
spinal meningitis,  823. 
injections    (see    also    Enemata    and    Irriga- 
tion), 
in   acute   milk   infection,   311;    in   dysentery, 
284,  286. 
Rectum,  congenital,  absence  of,  60. 
malformations  of,  59. 
narrowing  of,  59. 
diseases  of,  331. 
imperforate,  59. 

prolapse  of,  following  pertussis,  489. 
protrusion  of,  333. 
stimulation  by,  513. 

terminating  in  bladder,  69;  in  vagina,  60. 
Red  gum  (see  Miliaria  Rubra),  876. 
Reflex  cough,  449. 


Reflexes,    in   acute   myelitis,    806;    in   cerebral 
paralysis,  836;  in  spinal  paralysis,  811. 
patellar,     in     diphtheria,    552;     in     cerebro- 
spinal    meningitis,     826;     in     hereditary 
ataxy,  809;  in  pachymeningitis,  834. 
Regurgitation  of  food,  nasal,  443,  562. 
Rimini  test  for  formaldehyde  in  milk,  912. 
Remittent  fever  (see  Malarial  Fever),  706. 
Rennet,  action  of  milk  on,  124,  127. 
test  for,   in  gastric  contents,  916. 
Resection  of  ribs,  469. 
Resonance,   percussion,   451. 

vocal,  451. 
Respirations   (see  also  Breathing), 
artificial,  43. 
asleep,  11. 
awake,  11. 
Cheyne-Stokes,    in    tuberculous    pneumonia, 

515. 
in  bronchial  asthma,  455;  in  bronchitis,  453; 
in   broncho-pneumonia,    458;    in   infancy, 
11;     in    lobar    pneumonia,    506,    507;     in 
tubercular   meningitis,   826. 
wheezing,  455. 
Respiratory  system,  diseases  of,  425. 
Restlessness  at  night,   a  symptom  of  worms, 
328. 
in    constipation,    290;    in    gastroptosis,    255; 
in  rachitis,   351. 
Rest  treatment  in  chorea,  7S9. 
Resuscitation   of  the  new-born,  42. 

Byrd's  method,  43. 
Retraction  of  head,  in   cerebro-spinal   menin- 
gitis,  826;   in  epilepsy,   803;  in  influenza, 
482. 
Retro-oesophageal  abscess,   234. 
Retro-pharyngeal  abscess,  442. 
diagnosis,  443. 
pathology,  442. 
symptoms,   443. 
treatment,  444. 
complicating  cerebral  pneumonia,  503. 
lymph  adenitis,  442. 
Retro-pharynx  a  possible  point  of  entrance  of 

tubercle   bacilli,   518. 
Rhagades  of  anus  and  mouth  in  syphilis,  719, 

723. 
Rheumatic  torticollis,  747. 
Rheumatism,   acute,   740. 
bacteriology,  741. 
complications,    742. 
course,  742. 
etiology,  740. 
prognosis,  742. 
symptoms,    741  ;•  subcutaneous   tendinous 

nodules,  742. 
treatment,    743;    dietetic,    744;    medicinal, 
744;    prophylactic,   743. 
articular,   742. 
chorea  in,  742. 
following   tonsillitis,    741. 
muscular,  745. 
purpura  in,  742. 
Rhinitis  (see  Nasal  Catarrh),  425. 


INDEX. 


973 


Rhinolith,  429. 

Rhino-pharynx,     method     of     examining     for 

adenoids,  439. 
Rhythm,  451. 

Ribemont's  tube  for  inflating  the  lungs,  44. 
Ribs,  beaded,  in  rachitis,  342,  346. 

resection  of,  in   empyema,  469. 
Rice  water,  906. 
Rickets  (see  Rachitis),  341. 
Ringworm  (see  Tinea  Tonsurans),  878. 
Robert's  test  for  albumin  in  urine,  923. 
Roentgen  rays  as  diagnostic  aid,  14,  15. 
Rotary  spasm  of  head  (see  Spasmus  Nutans), 

785. 
Riothelen   (see  Rubella),  622. 
Round  worms,  328. 
Rubella,   622. 

bacteriology,  622. 

complications,   627. 

course,  627. 

desquamation,  625. 

diagnosis,  623:   differential,  625. 

eruption,  624. 

etiology,  622. 

pathology,  622. 

period  of  invasion,  623. 

prognosis,   627. 

symptoms,   623;   subjective,  625. 

treatment,  627. 
Rubeola  (see  Measles),  628. 
Rules   to   be   observed    in   taking  temperature 

of  infants,   12. 
Rupture   (see  also  Hernia). 

of  spleen,  in  malarial  fever,  710. 

Sacral  tumor,  congenital,  58. 
Saint  Vitus's  dance   (see  Chorea),  786. 
Salicylic-sulphur  paste,  871. 
Saline  solution,   for  colonic   flushings,   672;    in 
erysipelas,   705. 

cold,  in  typhoid,  699. 

subcutaneous  injections  of,  666,  672. 
Saliva,   action  of,   on  bacteria,   237. 

secretion  of,  at  birth,  2:36. 

in   stomatitis   gangrenosa,   227. 
Salt,   free  diet  in  scarlet  fever  and  nephritis, 

667. 
Sarcoma,  spindle-cell  of  the  thora.x,  884. 
Scabies,  883. 
Scalp,  fatty  growths  of  (see  Lipoma),  887. 

in  caput  succcdaneum,  58. 

ringworm  of,  878. 

seborrhnea  of,  876. 
Scarlatina   (see  Scarlet  Fever). 

papulosa,   651. 

post-operative,  661. 

sine  angina,  652. 

sine  exanthemata,  651. 

sine  febre,  651. 

variegata,  651. 
Scarlet   fever,  643. 

bacteriology,  645. 

complications,     652;     angina     ludovici,     655; 
coma,    065;    diphtheria,    V>7C,    072;    endo- 


carditis,   667;    heart,    058;    kidneys,    656; 
lungs,   660;    measles,   652;   nephritis,   665; 
otitis,      653;      pericarditis,      667;      retro- 
pharyngeal   abscess,    655;    thrombosis   of 
veins    of    Galen,     860;     whooping-cough, 
652. 
diagnosis,   663;   from  variola,  683. 
etiology,   643. 
incubation,  stage  of,  645. 
isolation,   664. 
pathology,   647. 
prognosis,  663. 
rash,   648. 

symptoms,   647;  tongue,  647;  urine,  648. 
treatment,   664;   diet,  667,   668;  hygienic,  664; 
medicinal,    670;    restorative,    667;    serum, 
668. 
varieties  of,  649;  septic,  650;  toxic,  049. 
vulvo-vaginitis   following,   402. 
Sciatica,  410. 
Schonlein's  disease,  748. 
Sclerema  neonatorum,  49. 
Scorbutus  (see  Scurvy),  335. 
Scrofula   (see   Tubercular  Adenitis),  755. 
lesions  of,  724. 

resembling  tuberculosis,  51/. 
Scurvy,   335. 
caused    by    prolonged    sterilized    milk    feed- 
ing, 161. 
diagnosis,  337. 
etiology,    335. 
pathology,   336. 
symptoms,  337. 
treatment,  340. 
Seborrhcea,  876. 

Secondary    anaemia,    734;    causes,    734;    diag- 
nosis,    734;     prognosis,    734;     symptoms, 
734;   treatment,  734. 
Seller's  solution,  428. 
Senses,  development  of,  2. 
Sensitive  skin,  18. 
Septic  diphtheria,  553. 
nephritis,    complicating   scarlet   fever,   657. 
omphalitis,  34. 
Serum   injection,    intraventricular   method  of, 

828. 
Serum   injections  in  premature  infants,  31. 

in   gastro-intestinal   bnsmorrhage,   39. 
Serum  test  for  typhoid,  692. 
treatment  of  diphtheria,   570;   of   dysentery, 
286;    of    erysipelas,    705;    of    meningitis, 
832;  of  scarlet  fever,  668;  of  tetanus,  801; 
of  typhoid,  698. 
Shiga  bacillus,  283. 
Shingles  (see  Herpes  Zoster),  873. 
Shock,    in    intussusception,    .325;    in    operative 

appendicitis,  318;   in  typhoid  fever,  699. 
Shoe,   proper,  19. 

Shoulders  in  lateral  curvature  of  spiuo,  897. 
Sigmoid  flexure,  260,  261. 

abnormalities  of,  289. 
Simple  catarrhal   proctitis.   331. 
SiiiKultus,   in  pericarditis.  :!7t'i:  In  typhoid,  69.S. 
Sitting,   when  established,  2. 


974 


INDEX. 


Skin,  cachectic,  in  syphilis,  723. 
diseases  of,  868;   blood  in,  728. 
in  Addison's  disease,  774;   in  chlorosis,   738; 
in    cretinism,    760;    in    eczema,    869;    in 
erythema     infectiosum,     674;      in     foutal 
ichthyosis,  46;   in  gastro-duodenitis.  251; 
in  meningitis,   827;   in  Mongolian   idiocy, 
846;  in  multiple  neuritis,  794;  in  pseudo- 
leuksemic     anaemia,     737;     in     secondary 
anaemia,  734;   in  Winckel's  disease,  50. 
sensitive,  18. 
Skull,  in  epilepsy,  802. 
in  hydrocephalus,  815. 
in  rachitis,  341. 
percussion  of,  775. 
Sleep,  as  diagnostic  aid,  14. 
examination   during,   9. 
proper  training,  22. 
pulse-rate  during,  10. 
restless   (see  Restlessness  at  Night). 
Small-pox  (see  Variola),  680. 
Smegma,  397,  398. 

Sneezing,  in  measles,  630;  in  rubella,  623. 
Sniffles   (see  Coryza). 

in  syphilis,  719'. 
Snoring,  a  symptom  of  hypertrophied  tonsils, 
435. 
in    adenoids,    439;    in    retro-pharyugeal    ab- 
scess, 443. 
Soap,  use  of,  18. 
Somatose,  205. 

Soor  (see  Stomatitis  Mycosa),  225. 
Sore  nipples,  93;  treatment  of,  93. 
Soson,  206. 

Spasm,   carpo-pedal,   798. 
clonic,  803. 
epileptic,  801. 

muscular,  in  rachitis,  346. 
of  bronchial  muscles,  455. 
of  glottis,  455. 

of  larynx,  455;   in  rachitis,  346. 
of  pylorus,  248. 
diagnosis,  248. 
symptoms,  248. 
treatment,  250. 
Spasmodic  cough,   448. 
■  croup,  444. 
laryngitis,  444. 
prognosis,  445. 

treatment,  445;  croup-kettle,  447;  emetics, 
447. 
stenosis,  248. 
Spasmus  nutans,  785. 

Spastic  diplegia  (see  Paralysis,  Cerebral),  834. 
Specific  gravity  of  blood,  at  birth,  727. 
of  milk,  62,  63. 
of  urine,  917,  921. 
Specific  laryngeal  stenosis,  720. 
Speech,   late   (see  also   Alalia   Idiopathica),   3, 
845. 
sudden  loss  of,  4. 
Spina  bifida,  807,  888. 
Spinal  brace,  898. 


cord,  in  acute  myelitis,  SGd;  in  chronic 
myelitis,  807;  in  tubercular  meningitis, 
819. 

malformations  of,   807. 
curvature,  897;  in  rachitis,  342. 
fluid,  in  meningitis,  826. 
Spindle-cell  sarcoma  of  the  thorax,  884. 
Spine,  abscess  of,  893. 
diseases   of,   890. 

in  Pott's  disease,  890;  in  rachitis,  346. 
lateral  curvature  of,  897. 
etiology,  897. 
prognosis,  897. 
symptoms,  897. 
treatment,  897. 
paralysis  of,  894. 
Spirochete  pallida,  718. 
Spleen,   diseases  of,  386. 
displacement  of,  in  constipation,  288. 
enlargement  of,  386. 

in  acute  tuberculosis,    530;   in   ansemia,   733; 
in    chlorosis,    738;    in    leuk£pmia,    735;    in 
malaria,  711;   in  malignant  endocarditis, 
375;  in  multiple  neuritis,  794;  in  pseudo- 
leukaemic   antemia,   737:    in  rachitis,   341; 
in  scarlet  fever,  661;  in  typhoid,  694. 
movable,  386. 
palpation  of,  386. 
rupture  of,  710. 
vifandering,  386. 
Splenic  antemia,  733. 
Split  proteids  in   infant  feeding,   122. 
Sponge  baths,   to  reduce  temperature,  513. 
Sponging,  cold,  23. 
Spontaneous  haemorrhage,  37. 
Spotted  fever  (see  Meningitis,  Epidemic),  824. 
Spray,   nasal,    427. 

throat,  434. 
Spray  bath,  cold,  in  hysteria,  793. 
Sprue  (see  Stomatitis  Mycosa),  225. 
Spurious,  cephalhsematoma,  58. 

hydrocephalus,  342. 
Sputum   (see   also   Expectoration), 
disinfection  of,   935. 
in   bronchitis,    453;    in    tuberculosis,    532;    in 

typhoid,  700. 
test  for  tubercle  bacilli  in,  928. 
Square  cranium  in  rachitis,  342,  346. 
Squinting,   12. 
Stammering,  786. 

Staphylococci,   in   bronchitis,  452;  in  broncho- 
pneumonia,   457;    in    diphtheria,    543;    in 
empyema,     467;     in     erysipelas,     702;     in 
follicular  tonsillitis,  432;  in  measles,  628; 
in    perinephritis,    409;    in    pleurisy    with 
effusion,  464. 
Starch,    127;   chemistry  of,   129. 
digestion,  128. 
transformation  of,  128. 
Statistics   (see   also  Mortality), 
bacteria    in    unripened    and    ripened    cream, 

136. 
diphtheria,   bacteria  in,  548. 
immunity  from,  569. 


INDEX. 


975 


statistics  (concluded). 

rashes,    following  injection  of  antitoxin, 

555. 
intubated  cases  of,  581. 
measles  with  ear   complications,   639. 
mothers,  percentage  of,   able  to  nurse,  80. 
unable  to  wet-nurse,  83. 
Status  lymphaticus,  753. 
Steak  juice,  211. 

Steam  inhalations  (see  Inhalations). 
Stenosis,   congenital,   of  larynx,   56. 
hypertrophic,  of  the  pylorus,  248. 
laryngeal,    following    intubation    and    decu- 
bitus, 609. 

etiology,    609;    pathology,    610;    treat- 
ment, 612. 
in  diphtheria,  551,  572,  579. 
in  retro -pharyngeal  abscess,  443. 
intubation  in,  592. 
recurring,   600. 
pulmonary,  369. 
spasmodic,  248. 
sub-glottic,  in  syphilis,  721. 
Stercoraceous  vomiting  (see  Faecal  Vomiting). 
Sterilization  of  milk,  159. 
causing  constipation,    162. 
chemical  changes  produced  by.   111. 
disadvantages  of,  161. 
scurvy,  caused  by,   161,  337. 
Sterilizers,  milk,  164. 
Sterno-mastoid,  hsematoma  of,  57. 
Sternum,  prominent,  57;  depressed,  57. 
Stethoscopes,  364. 
Stimulant,  coffee  as  a,  213. 

whisky  as  a,  214,  513. 
Stomach,  acids  in,  237. 
anatomy  of,   236. 
capacity,  239. 
diseases  of,  236. 
haemorrhage   from,    in    exophthalmic   goiter, 

772. 
infantile,  236. 
low  position  of,   255. 
motor  function  of,  916. 
mucous  membrane  of,  236. 
physiology  of,  236. 
translumination   of,    254. 
ulcer  of,  257. 

unorganized  ferments  in,  237. 
Stomach-washing,  307. 

in  acute  gastric  catarrh,  244;  in  chronic 
gastrititis,  253;  in  summer  diarrhoea, 
307. 
technique  of,  308. 
Stomatitis,  222. 

complicating  scarlet  fever,   660. 
in  athrepsia,  .3.57;   in  syphilis,   725. 
aphthosa,    223;    causes,    223;    diagnosis,    224; 

symptoms,  224:   treatment,  224. 
catarrhalis,    222;    symptoms,    223;    prognosis, 

223;  treatment.  223. 
croupous  or  diphtheritic,  22G. 
gangrenosa,   227. 
mycosa,  225;  symi)toms,  225;   treatment,  226. 


syphilitic,   227. 
Stone  in  the  bladder,  420. 

Stool,  casein  in,  264;  curds,  -white  in,  265; 
diastatic  enzymes  in,  69;  excess  of  fat 
in,  265;  peptonizing  ferment,  265;  pro- 
teids  in,  264;  reaction  of,  262;  saccharine 
ferment,  265;  sugar  in,  265;  quantity  of, 
264. 
l)loody,  263,  559;  in  Henoch's  purpura,  750; 
in  intussusceptions,  323;  in  syphilis,  719. 
brown,  263. 

disinfection  of,  935;   in  typhoid,  700. 
dry  pasty,  265. 
green,  263. 

in   athrepsia,   357;    in   derangement  of  liver, 
382;    in    dysentery,    284;    in   gastro-duod- 
enitis,    251;    in   gastro-intestinal    hcemor- 
rhage    (melsena),    38;    in    scarlet    fever, 
toxic,  650;  in  typhoid,  693. 
lienteric,  299. 
mucus,  263. 
of    buttermilk-fed    infant,    186;    of   nursling, 

262. 
thin,  watery,  149. 
white  or  light  gray,  264. 
Strabismus,   following  cerebral  paralysis,  836. 
cerebro-spinal  meningitis,  826. 
pertussis,   489. 
in  tubercular  meningitis,  820. 
Streptococci,     in     acute     peritonitis,     388;     in 
bronchitis,    452;    in    broncho-pneumonia, 
457;  in  erysipelas,  702;  in  empyema,  467; 
in   follicular   tonsillitis,   432;    in   measles, 
625;   in  meningitis,   827;  in  perinephritis, 
409;    in    pleurisy    with    effusion,    464;    in 
pseudo-diphtheria,   619. 
stain   for,   929. 

smear   from   throat   exudate,   545. 
Strepto-diplococcus  in  scarlet  fever,  645. 
Streptolytic    serum    in    treatment    of    scarlet 

fever,  669. 
Strophulus    infantum    (see    Miliaria    Rubra), 

876. 
Stupe,  turpentine,  937. 

Stuttering,  786;  a  sequela  to  scarlet  fever,  786. 
Stye,  867. 

Subacute  milk  infection,  311. 
Subarachnoid  space,  fluid  in,  778. 

haemorrhage  into,  778. 
Subcutaneous  haemorrhage  in  scurvy,  337. 
tendinous   nodules,   in   rheumatism,   742. 
Submaxillary   glands,    in    diphtheria,   551,   553; 

in  scarlet  fever,  647,  655. 
Subnormal    temperature,    in    athrepsia    infan- 
tum, 358;   in   bronchitis,  453;  in  myocar- 
ditis, 379. 
Subphrenic   abscess,   385. 
Substitute  foods,  182. 
Sucking,  236. 
Sudaniina,  870. 

Sudden    death,    caused    by    enlarged    thymus, 
753,   773. 

careless  Injection  of  antitoxin,  570. 
in  diphtheria,  559,  564. 


976 


INDEX. 


Sudden  death  (concluded), 
in  myocarditis,  379. 
in  pertussis,   489. 
Suffocation  from  vomited  milk,  26. 
Sugar,  excess  of,  causing  colic,  296. 
nutrient  value  of,   120. 
cane,  119. 
in  urine   (see  Glycosuria). 

test  for,  925. 
milk,   119. 
Sulphur  baths,  8.31. 
Summer  diarrhoea,  311. 

Sunlight,    in    treatment    of    chlorosis,    739;    of 
peritonitis,    392;    of   tuberculosis,    534;    of 
typhoid,  700. 
Sunstroke   (see  Insolation),  851. 
Supplementary  head,  58. 
Superficial  gangrene,  881. 
Suppositories,   292. 

in  constipation,  292;   in  dysentery,  2SG. 
Suprarenal  capsules,  405. 

Sutures,  separation  of,  in  hydrocephalus,  815. 
Sweating,  head,  in  rachitis,  346. 
in  acute  tuberculosis,  535;  in  malarial  fever, 
714;  in  very  young  infants,  12. 
Symmetrical  gangrene,  883. 
Symptoms  and  diagnosis  (see  Diagnostic  Sug- 
gestions),  9. 
Syncope  in  pericarditis,  376. 
Synovitis,   complicating  scarlet  fever,   656. 
followed   by   knee-joint  disease,   905. 
purulent,  903. 
Syphilis,  716. 

diagnosis,  723. 

differential,      723;      from      scrofulous 
lesions,     724;     from    tuberculosis, 
723;   from  variola,  685. 
modes  of  infection,   716. 
pathological  anatomy,  718. 
prognosis,  724. 
specific  laryngeal  stenosis  in,  720. 

intubation  in,  592. 
spirochete  pallida,   718. 

refringens,  718. 
stomatitis  in,  725. 

symptoms,     bones,     718;     haemorrhages, 
719;    lesions,    724;    skin    lesions,    720; 
teeth,  721,  722. 
transmission  of,  724. 
treatment,   725. 

Wassermann   reaction  in,  723. 
haemorrhagic,  719. 
hereditary   (see  Inherited), 
inherited,  716. 

Colles's   law,   717. 
contagion  of,   717. 
Syphilitic  stomatitis,  227,  725. 
Syphilitic   teeth,   721,  722. 
Syringe,  nasal,  427. 
Systolic  murmurs,  3G6. 

Tache  cerebrale  in  tubercular  meningitis,  82(i. 
Tachycardia,  366. 


in    diphtheria,    552;    in   exophthalmic   goiter, 
772. 
Ttenia,    cucumerina,    326. 

mediocaiiellata,   326. 

sodium,  326. 
Talipes,   congenital,   with  rachitis,  355. 
Tannin-sulphur  paste,  880. 
Tapeworms,   326. 

Tapping  the  abdomen  in  ascites,  394. 
Tea,  215. 
Teeth,  eruption  of,  7. 

grinding  of,  a  symptom  of  worms,  328. 

hygiene  of,   16. 

in    adenoid    vegetations,    438;    in    cretinism, 
760;    in    rachitis,    345;    carious,    346;    in 
stomatitis   gangrenosa,    228;    in    syphilis, 
721,  722. 
Teething   (see   Dentition). 
Temperature   (see  also  Fever),  11. 

as  a  diagnostic   aid,   11. 

how  to  reduce,   511. 

in    distinguishing    the    still-born    from    the 
dead,   43. 

normal  fluctuations,  11. 

rules  in  taking,  11. 

variations  in,  472. 
Tender  nipples,   94;   treatment  of,   94. 
Tenesmus,    in    colicystitis,    419;    in   dysentery, 
285;    in    intussusception,    322;    in    vesical 
calculi,  420. 
Tertian  intermittent  fever,  706. 
.    double,  706. 

Testicle,    in    hydrocele,   397;   in  orchitis,   com- 
plicating mumps,  758. 

tuberculosis   of,  519. 

undescended,  399. 
Tetanic  seizures  in  rachitis,  346. 
Tetanus,   800. 

bacteriology,   800. 

etiology,  800. 

pathology,  800. 

prognosis  and  course,  801. 

treatment,  801. 

antitoxin,  801. 
Tetany,  798. 

course,  799. 

etiology,   798. 

prognosis,  799. 

symptoms,  799. 

treatment,  799. 

Trosseau's  sign  in,  799. 
Thermometer,    bath,   18. 

clinical,  disinfection  of,  934. 
Thirst,    excessive    in    diabetes    insipidus,    416; 
in     diabetes     mellitus,     419;     in     gastric 
catarrh,   243;    in   gastro-duodenitis,  250. 

in  diarrhoea,   277. 
Thoracoplasty  in  chronic  empyema,  471. 
Thorax,  depression  of,  in  rachitis,  346. 

lin   empyema,   468. 

spindle-cell  sarcoma  of,  884. 
Threadworms,  329. 
Throat,  as  diagnostic  aid,  13. 

diseases  of,  425. 


INDEX. 


977 


Throat  (concluded), 
ice-bag,   434. 

in  diphtheria,  558;  in  gastro-duodenitis,  251; 
in  rubella,  623;  in  scarlet  fever,  647,  670. 
spray,  434. 
Thrombosis,    in   diphtheria,   559;   in   gangrene, 
881. 
of  cerebral  sinuses,  860. 
of  pulmonary  artery,  559. 
Thrush   (see  Stomatitis  Mycosa),  225. 

resembling  diphtheria,  558. 
Thymic  asthma,  773. 
Thymo-chloroform  oil   (Morris's),  880. 
Thymus,  753. 
diseases  of,  773. 
enlarged,  753. 

primary  tuberculosis  of,  519. 
Thyroid,  abnormality  of,  773. 
desiccated,  extract  of,  in  cretinism,  771. 
implantation,   772. 

in    exophthalmic    goiter,    772;    in    leukaemia, 
735. 
Thyroiditis  acute,   773. 
Tibia,  in  rachitis,  348. 
Tic,  787. 
Tinea  tonsurans,  878. 

versicolor,  873. 
Tongue,  as  diagnostic  aid,  13. 
bifid,  232. 

epithelial   desquamation   of,    231. 
hypertrophy  of,  congenital,  232. 
in   chorea,    788;    in   cretinism,    760;    in   diph- 
theria,   551,    553;    in    gastritis,    chronic, 
252;  in  glossitis,  232;  in  measles,  630,  6.33; 
in  rubella,  623;   in  scarlet  fever,  647. 
tubercular  infection  of,  519. 
ulceration  of,   in  pertussis,  488. 
Tongue  depressor,  14. 
Tongue-tie,   55. 

Tonics,   restorative,   667;    nutritive,  205. 
Tonsils,  enlarged,  435. 

causing  bronchial  asthma,  455. 
indications  for  removal,  435. 
predisposing    to   laryngeal    stenosis,    599. 
in  diphtheria,  .551,  553;   in  leukaemia,   735. 
tuberculosis  of,  437. 
Tonsillitis,   430. 

bacteriology,  430. 
pathology,  430. 
symptoms,  4.30. 

sequelae,  chorea,  788;  rheumatism,  741. 
significance  of,   431. 
treatment,  430. 
croupous,  432. 
follicular,  431. 
hypertrophic,   chronic,  434. 
phlegmonous,  433. 

ulcero-membranous,   4:;2. 
Tonslllotomo,   Haginsky,  43G;   Mackenzie,   436. 
Tonsillotomy,   4.30. 

bleeding   flolowing,   435,   430. 
indications  for,  435. 
Top-milk,    1.37. 
Torticollis,   746. 


etiology,   746. 
symptoms,  747. 
treatment,  747. 
medicinal,  747. 
surgical,  747. 
acquired,  746. 
acute,  746. 
chronic,  746. 
congenital  746. 
ocular,  746. 
psychical,  746. 
rachitic,  746. 
spasmodic,  716. 
To.xEemia,   in  auto-intoxication,  322;   in  dysen- 
tery, 285. 
interstitial,   causing  tetany,  798. 
Toxin,  diphtheria,    effect  of,   on   nervous  sys- 
tem of  animals,  549,  550. 
in  scarlet  fever,  647,  650. 
Toxins  (see  also  Poisons), 
causing  convulsions,  781. 
elimination  of,   576. 
Trachea,    cannula,    silver,    610;    hard    rubber, 
616. 
stenosis  of,  581. 
Tracheotomy,  in  laryngeal  stenosis,   615. 
operation,   616;    anesthetic,   616. 
after-treatment,   617. 
in  syphilitic  sub-glottic  stenosis,  721. 
Trachoma   (see  Granular  Ophthalmia),   864. 
Translumination  of  stomach,  254,  255. 
Traumatism,     causing     acute     arthritis,     903; 
aphthae,    16,    225;    cerebral    abscess,    843; 
epilepsy,  802;  joint  disease,  901. 
Trophonine,  as  a  substitute  food,  156. 
Tropon,  206. 

Trosseau's  sign  in  tetany,  799. 
Truss,  in  umbilical  hernia,  326. 
Tubercle  bacilli,   dessiminated  by  cows,  107. 
in     tubercular     perinephritis,     410;     in     the 

urine,  920. 
stain  for,   in  sputum,  928. 
transmission  of,   520. 
Tubercular  empyema,   471. 
hip-joint   disease,   898. 
meningitis,  819. 

ulceration  of  the  intestine,  538. 
Tuberculin  test,  for  diagnosis,  533. 
cutaneous  reaction   (Pirquet),   533. 
of  pure  bred  cattle,  106. 
ophthalmo  reaction   (Calmette),  533. 
Tuberculosis,    following    cerebral    pneumonia, 
509;     chlorosis,    738;     empyema,    471; 
scrofulosis,  517. 
in  the  new-born,   .52,  517. 
manifestations   in    bladder,   421. 
modes  of  infection,  518. 
mortality  statistics,  524,  527,  528,  529. 
ratio    of,     between     the    whites    and 
colored,   525,  526. 
of  hip-joint,   898. 
of      pericardium,      378;      diagnosis,     378; 

treatment,  378. 
of   tonsils,    437. 


978 


INDEX. 


Tuberculosis  (concluded). 

predisposing  causes,  519. 
acute,  516. 

bacteriology,  519. 
diagnosis,    5o2. 

from  syphilis,  723;  from  typhoid,  532. 
sputum.  532;   blood  in,   535. 

method    ot    obtaining,    532. 
tuberculin   reaction,   533. 
etiology,  516. 

cows'  milk,  516. 
raw   milk,   517. 
woman's  milk,   516. 
pathological  anatomy,  521. 

lung,    521,    523. 
prognosis,  533. 
symptoms,  530. 
aneemia,  530. 
cyanosis,  530. 
night  sweats,  535. 

physical  signs,  530;  in  nurslings,  531. 
resembling   intermittent   fever,   530. 
temperature,  530. 
treatment,   534. 
diet,  534. 
general,  534. 
hygienic,  534. 
medicinal,   535. 
bovine,  516. 

chronic  pulmonary,  535. 
pathology,  536. 
lesions,  536. 
lung,  537. 
symptoms,  537. 
antemia,    538. 

dyspnoea   and   cyanosis,    538. 
expectoration,  538. 
pleuritic  pains,  538. 
mortality,  524. 
treatment,  538. 
miliary  (see  Acute), 
rubcrculous  adenitis,   442. 
ankle-joint   disease,   902. 
broncho-pneumonia,    .535;    coxitis,    899. 
elbow-joint  disease,  902. 
hip-joint  disease,  898. 
infection   through  milk,   105,   115,  516. 
knee-joint  disease,  901. 
nodules,  820. 
pneumonia,  514. 

following   diphtheria,    515;    measles,    515; 
whooping-cough,    515. 
wrist-joint  disease,   902. 
Tumor  of  bladder,  421. 
of   intestine,   288. 
of  kidney,  414. 
sacral,  congenital,  58. 
spindle-cell   sarcoma  of  thorax,  884. 
spongy  (see  Angoioma),  53. 
Tunica  vaginalis,  hydrocele  of,  397. 
Turbinates,  hypertrophied,  455;  causing  bron- 
chial asthma,  455. 
Turpentine  stupes,  937. 
Twitching,  in  chorea,  788;   in  meningitis,  822. 


Tympanites   (see  Intestinal   Colic),  296. 
a  symptom  of  worms,  328. 
complicating  typhoid,   698. 
in   intussusception,  324. 
Typhoid   bacillus   in   perinephritis,   409. 
Typhoid  fever,  689. 

bacteriology,  690. 

complications,  698;   aphasia,  698;   chorea, 
698;  otitis  media,  698;  peritonitis,  698. 
course,  G98. 
diagnosis,   694. 

differential,  696;  from  cholera  infan- 
tum,   696;     from    diarrhoea,    697; 
from  malaria,   696. 
eruption,  695. 
etiology,   689. 

internal  haemorrhage,  097. 
intestinal  perforation,  687. 
leucopcemia  in,  696. 
mortality,   690. 
pathology,  690. 
prognosis,  698. 
symptoms,  693. 

temperature,   693. 
sequela,  tetany,  798. 

treatment,  698;  bath,  699,  732;  food,  700. 
foetal  and  infantile,  691. 

Uffelmann's   test   for   lactic   acid   in   stomach- 
contents,  915. 
Ulcer,  In  scrofula,  724;  in  syphilis,  724. 
of  frenum  of  tongue,  488. 
of  stomach,  257,  738. 
diagnosis,  527. 
prognosis  and  course,  257. 
symptoms,  257. 
treatment,   258. 
of  tonsil,   432. 

tubercular  of  intestine,  538. 
Ulcerations,  aphthous,  223. 

due  to  wearing  of  intubation  tube,   596. 
Ulcerative  proctitis,   332. 
Ulcero-membranous  tonsillitis,   432. 

resembling  diphtheria,  558. 
Umbilical  cord,  16;  heemorrhage  of,  38. 
after-treatment,   17. 
ha?morrhage  in  syphilis,  719. 
hernia,  325;  causes,  325;  treatment,  325. 

following  pertussis,  489. 
polypus,  34. 
Umbilicus,  bleeding  from,  33. 
in  Meckel's  diverticulum,  34. 
management  of,  16. 
Undescended   testicle,   399." 
Undiluted  milk  as  a  food  for  infants,  115. 
Unna's  soft  zinc  paste,  870. 
Uraemia  in  post-scarlatinal  nephritis,  659. 
Ursemic   convulsions   in    nephritis,    complicat- 
ing diphtheria,   552. 
Urea  in  diabetes  insipidus,  416. 
Urethra  in  vaginitis,  402. 
Urethral  calculi,  420. 
Urethritis,  400. 
Uricacidaemia   (see   Lithaemia),  750. 


INDEX. 


979 


Uric  acid,    in  the  blood,   750. 

in  urine,  920;   of  new-born,  918. 
Urine,  917. 

albumin  in,  918;  test  for,  921. 

bloody,  417. 
Diazo  reaction  in,  923;  in  typhoid,  695,  697. 

disinfection  of,  935;   in  typhoid,  700. 

fermentation  test,  927. 

first,  917. 

in  atrophy,  infantile,  915;  auto-intoxication, 
322;  in  coiicystitis,  419;  in  cystitis,  421; 
in  derangement  of  liver,  382;  in  diabetes 
insipidus,  416;  in  diphtheria,  552,  919;  in 
epilepsy,  806;  in  gastro-duodenitis,  251; 
in  glycosuria,  418;  in  hsematuria,  417; 
in  h£pmoglobiuuria,  418;  in  icterus  neo- 
natorum, 918;  in  leukaemia,  920;  in 
lithaemia,  751;  in  measles,  633;  in  neph- 
ritis, 406,  407,  919;  in  pertussis,  489;.  in 
pneumonia,  508;  in  pyelitis,  412;  in  scar- 
Igt  fever,  648,  650,  651;  in  septic  diph- 
theria, 553,  559,  562;  in  typhoid,  695,  697, 
700;  in  tuberculosis,  530. 

in  continence  of,  in  multiple  neuritis,  794; 
in  ectopia  vesicae,  413. 

indican,   test  for,   925. 

method  of  collecting,   917. 

of  breast-fed  babies,  917;  of  new-born 
babies,   918. 

sodium  chloride  in,  918. 

specific  gravity,  921. 

sugar  in,  418;  test  for,  925. 
Urino-pyknometer,  920. 
Urticaria,  871. 

causes,  871. 
symptoms,  872. 
treatment,  872. 

following    administration    of    antitoxin,    872; 
of  drugs,  872. 

gastro-intestinal  disturbances,  872. 
Useless  coughs,   449. 
Uvula,  bifid,  232. 

enlarged,  causing  bronchial  asthma,  <!i)5. 

inflamed,   in   spasmodic   laryngitis,   444. 
section  from,   547. 

in  scarlet  fever,   647. 

Vaccination,  686. 

complications,   686. 

method   of,   687. 

site  of  inoculation,  686. 

mortality    of    vaccinated    and    uuvacci- 
nated,  687. 

symptoms,  .686. 
accidental,  on  cheek,  687. 
Vaccine,   varieties  of,  686. 
Vaccinia,  686. 

eruption,  688. 

symptoms,  688. 
Vagina,  rectum  terminating  in,  60. 
Vaginitis,  400. 

bacteriology,   401. 

complications,  402. 

etiology,  401. 


catarrhal,  400. 
gonorrhoeal,  400. 
simple,  400. 
vulvo,   400. 

following  scarlet  fever,  402. 
Vasomotor  disturbance,  causing  asthmatic  at- 
tacks, 455. 
Varicella,  676. 
complicating  erysipelas,   678. 
diagnosis,  676. 

differential,     677;     from     impetigo,     678; 
from  variola,  677. 
etiology,  676. 
pathology,   676. 
prognosis,  678. 
treatment,  678." 
Variola,  680. 
complications,  685;   broncho-pneumonia,  685; 

oedema  of  glottis,  685;   otitis,  685. 
desquamation,    682. 

diagnosis,    differential,    683;    from    chicken- 
pox,  685;  from  impetigo,  683;  from  scar- 
let fever,    683;   from   syphilis,    685;    from 
typhoid,   in  early  stages,  683. 
eruption,  681. 
etiology,   680. 
isolation,  685. 
mode  of  infection,   681. 
mortality,  680. 
prognosis  and  course,  685. 
symptoms,    681. 

stage  of  decline,  680;  of  suppuration,  682. 
treatment,  685. 
Varioloid,   685. 
Vascular  nsevus,   878. 
Vegetable  milk,  Lahmann's,  187. 
Veins,  engorgement  of,  in  insolation,  851. 
of  abdomen,  in  ascites,  392. 
of  scalp,   in  hydrocephalus,  810;   in  rachitis, 

346. 
splenic,  in  malarial  fever,  711. 
varicose,   in   chlorosis,   738. 
Vein,    transverse    nasal,    in    adenoid    vegeta- 
tions, 4.39. 
umbilical,   361. 
Velum  palatinum,  in  diphtheria,  551,  553. 
Venesection,  938. 
Venous  murmurs,   308. 
Vermiform  appendix,   location  of,  261. 
Vernix  caseosa,  17. 
Verruca,  880. 

Vertigo,  a  symptom  of  worms,  328. 
Vesical  calculi,  420. 
Vicarious  menstruation,  404. 
Vincent's  bacillus,  4:!3. 
Vocal  resonance,  451. 
Voice,   husky,   in  papillomata,  888. 
in    pleurisy   witli    effusion,    465;    In   syi)liilis, 

723. 
nasal,  in  diphtheria,  550,  562. 

with  hypertrophy  of  tonsils,  4.35. 
Vomiting,   caused  by  excess  of  proteids,   123. 
chronic,  251. 
cyclic,   258. 


yso 


IXJJKX. 


Vomiting  (coucluded). 

fii'cal,   iu   intussusception,  323. 

in  dilatation  of  stomach,  254;  in  diphtheria, 
552;  in  Henoch's  purpura,  750;  in  hyper- 
trophic pyloric  stenosis,  249;  in  influenza, 
480;  iu  measles,  630;  in  meningitis,  822, 
826;  in  pachymeningitis,  833;  in  pertus- 
sis, 490;  in  premature  infants,  31;  in 
rubella,  623;  in  scarlet  fever,  645,  651; 
in  spinal  paralysis,  811;  in  typhoid,  693. 

significance  of,  242. 
Vulvo-vaginitis,  400. 

catarrhal,  400. 

gonorrhffal,  400. 

bacteriology,  401. 

complications,   402;    eye,   402;   heart,   402; 

joint,   402;   pyelitis,   402. 
etiology,  401. 
mode  of  infection,  401. 
treatment,  403;   vaccine  injections,  403. 

simple,  400. 

bacteriology,    400. 
etiology,   400. 

following  scarlet  fever,  402. 
prognosis^  403. 
symptoms,    400. 
treatment,  403. 

Walking,  first  attempts  at.  2. 
in    congenital    dislocation    of    hip,    900;     in 
hereditary   ataxy,   809. 
Wampole's  milk  food,  198;  analysis  of,  199. 
Wandering   pneumonia,    499. 

spleen,  386. 
Warts  (see  Verruca),  880. 

syphilitic,   725; 
Wassermann  reaction  in  syphilis,  723. 
Wasting    disease    (see    Athrepsia    Infantum), 

356. 
Water-ices,  212. 

Water  on  the  brain   (see  Chronic  Hydroceph- 
alus), 814. 
Waxy  liver,  383. 
Weaning,  90,  91. 
diflicult,  91. 
during  pregnancy,  90. 
Weighing  to   determine   the  quantity  of   milk 

an  infant  has  taken,  217. 
Weight  at  birth,  217. 
gain  in,   of  an  infant  fed  on   Eskay's  food, 
219. 


on  modified  milk,  220. 
on  mother's  milk,  217. 
on  Walker-Gordon  modified  milk,  220. 

of   a    prematurely   born   infant,   wet-nursed, 
219. 

loss  of,  during  first  week,  G7. 

of  premature  infant,  31. 
Weight-scale,   Chatillon,  216. 
Wcrlhofs     disease     (see      Purpura      Ilirmor- 

rhagica),    748. 
Wet-nurse,  80. 

child  of  a,  81. 

dangers  of  syphilis,  84,  227. 

diet  of  a,  86. 

for  weak  and  marasmic  infant,  SO. 

health  of  a,  81. 

how  to  examine,  80,  82. 

manner  of  living,  86. 

proper  rest  for,  86. 

selection  of,  80,  83. 

tricks  of,  81. 

with  goiter,  81. 
Wet-nursing,  in  New  York,  89;  in  Prague,  88. 
Wheal,   in  urticaria,  872. 
Whey,  910;  as  a  diluent,  122. 
Whitney's  test  for  sugar  in  urine,  926. 
Whooping-cough    (see  Pertussis),   486. 
Widal's  reaction   in  typhoid,   694. 

stages  in,  694. 
Winckel's  disease,  50. 
Woman's  milk   (see  Milk). 
Woodward's   burette   for   estim.nting   proteids, 

124. 
Worms,   causing  convulsions,  781,  783. 

pinworms,  329. 

round  worms,  328;  diagnosis,  329;  treatment, 
329. 

tapeworm,    326;    diagnosis,    327;    symptoms, 
327;   treatment,   327. 

threadworm,  329. 
Wrist-joint  disease,  902. 

in  rachitis,  342. 
Wry-neck    (see   Torticollis),  746. 

X-ray  examination,  as  diagnostic  aid,  14. 
difficulty  in  making,  15. 
of  congenital  dislocation  of  hip,  900. 

Yawning,   in  malarial   fever,  715. 

Zoolak,  209;  analysis  of,  209. 


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